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+"history of present illness:  this is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for q-fever endocarditis.  he is also taking digoxin, aspirin, warfarin, and furosemide.  mother reports that he does have problems with 2-3 loose stools per day since september, but tolerates this relatively well.  this has not increased in frequency recently. mark recently underwent surgery at children’s hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of gore-tex membrane pericardial substitute.  he tolerated this procedure well.  he has been doing well at home since that time. physical examination:vital signs:  temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.general appearance:  well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.heent:  remarkable for the badly degenerated left lower molar.  funduscopic exam is unremarkable.neck:  supple without adenopathy.chest:  clear including the sternal wound.cardiovascular:  a 3/6 systolic murmur heard best over the upper left sternal border.abdomen:  soft.  he does have an enlarged spleen, however, given his obesity, i cannot accurately measure its size.gu:  deferred.extremities:  examination of extremities reveals no embolic phenomenon.skin:  free of lesions.neurologic:  grossly within normal limits. laboratory data:  doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  hydroxychloroquine level obtained at that time was undetectable.  of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/ml.  q-fever serology obtained on 10/05/2007 was positive for phase i antibodies in 1/2/6 and phase ii antibodies at 1/128, which is an improvement over previous elevated titers.  studies on the pulmonary valve tissue removed at surgery are pending. impression:  q-fever endocarditis. plan:  1.  continue doxycycline and hydroxychloroquine.  i carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  she assures me that he is compliant with his medications.  we will however repeat his hydroxychloroquine and doxycycline levels.2.  repeat q-fever serology.3.  comprehensive metabolic panel and cbc.4.  return to clinic in 4 weeks.5.  clotting times are being followed by dr. x."
+"reason for consult: renal insufficiency. history of present illness: a 48-year-old african-american male with a history of coronary artery disease, copd, congestive heart failure with ef of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. the patient denies any chest pain, palpitations, syncope, or fever. denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. nephrology is consulted regarding renal insufficiency. review of systems: reviewed entirely and negative except for hpi. past medical history: hypertension, congestive heart failure with ejection fraction of 20%-25% in december 2005, copd, mild diffuse coronary artery disease, and renal insufficiency. allergies: no known drug allergies. medications: clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, lipitor 20 at bedtime, toprol xl 100 daily. family history: noncontributory. social history: the patient denies any alcohol, iv drug abuse, tobacco, or any recreational drugs. physical examination:vital signs: blood pressure 180/110. temperature 98.1. pulse rate 60. respiratory rate 23. o2 sat 95% on room air.general: a 48-year-old african-american male in no acute distress.heent: pupils equal, round, and reactive to light and accommodation. no pallor or icterus.neck: no jvd, bruit, or lymphadenopathy.heart: s1 and s2, regular rate and rhythm, no murmurs, rubs, or gallops.lungs: clear. no wheezes or crackles.abdomen: soft, nontender, nondistended, no organomegaly, bowel sounds present.extremities: no cyanosis, clubbing, or edema.cns: exam is nonfocal. labs: wbc 7, h and h 13 and 40, platelets 330, pt 12, ptt 26, co2 20, bun 27, creatinine 3.1, cholesterol 174, bnp 973, troponin 0.18. previous creatinine levels were 2.7 in december. urine drug screen positive for cocaine. assessment: a 48-year-old african-american male with a history of coronary artery disease, congestive heart failure, copd, hypertension, and renal insufficiency with:1. hypertensive emergency.2. acute on chronic renal failure.3. urine drug screen positive.4. question chf versus copd exacerbation. plan:1. most likely, renal insufficiency is a chronic problem. hypertensive etiology worsened by the patient’s chronic cocaine abuse.2. control blood pressure with medications as indicated. hypertensive emergency most likely related to cocaine drug abuse. thank you for this consult. we will continue to follow the patient with you."
+"indications:  this is a 55-year-old female who is having a colonoscopy to screen for colon cancer.  there is no family history of colon cancer and there has been no blood in the stool. procedure performed:  colonoscopy. prep:  fentanyl 100 mcg iv and 3 mg versed iv. procedure:  the tip of the endoscope was introduced into the rectum.  retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  the rest of the colon through to the cecum was well visualized.  the cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified.  there was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  adverse reactions none. impression:  normal colonic mucosa through to the cecum.  there was no evidence of tumor or polyp."
+"comments:1.  the left ventricular cavity size and wall thickness appear normal.  the wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  there is near-cavity obliteration seen.  there also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  there is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by doppler examination.2.  the left atrium appears mildly dilated.3.  the right atrium and right ventricle appear normal.4.  the aortic root appears normal.5.  the aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.6.  there is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.7.  the tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  estimated pulmonary artery systolic pressure is 49 mmhg.  estimated right atrial pressure of 10 mmhg.8.  the pulmonary valve appears normal with trace pulmonary insufficiency.9.  there is no pericardial effusion or intracardiac mass seen.10.  there is a color doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.11.  the study was somewhat technically limited and hence subtle abnormalities could be missed from the study."
+"2-d m-mode:  1.  left atrial enlargement with left atrial diameter of 4.7 cm.2.  normal size right and left ventricle.3.  normal lv systolic function with left ventricular ejection fraction of 51%.4.  normal lv diastolic function.5.  no pericardial effusion.6.  normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.7.  pa systolic pressure is 36 mmhg. doppler:  1.  mild mitral and tricuspid regurgitation.2.  trace aortic and pulmonary regurgitation."
+"a 21-channel digital electroencephalogram is performed on the patient, predominantly in a drowsy and sleepy state.  in brief periods of wakefulness, significant muscle artifact is noted bilaterally.  with drowsiness, the recording slows, and with the sleep, vertex activity is noted.  recording is somewhat disorganized for age with intermixed theta and alpha activity.  at times, higher voltage slowing is noted over the right compared to the left hemisphere head regions.  rare sharp wave activity is noted generally on the right over the c4 electrode, but rarely on the left over the t3 electrode.  no spike-and-wave activity is noted. 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."
+"cc: slowing of motor skills and cognitive function. hx: this 42 y/o lhm presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. he had difficulty holding a job. his most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. for 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). his walk became slower and he had difficulty with balance. he became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. his wife noticed "fidgety movements" of his hand and feet. he was placed on trials of sertraline and fluoxetine for depression 6 months prior to presentation by his local physician. these interventions did not appear to improve his mood and affect. meds: fluoxetine. pmh: 1)right knee arthroscopic surgery 3 yrs ago. 2)vasectomy. fhx: mother died age 60 of complications of huntington disease (dx at uihc). mgm and two ma’s also died of huntington disease. his 38 y/o sister has attempted suicide twice. he and his wife have 2 adopted children. shx: unemployed. 2 years of college education. married 22 years. ros: no history of dopaminergic or antipsychotic medication use. exam: vital signs normal. ms: a&o to person, place, and time. dysarthric speech with poor respiratory control. cn: occasional hypometric saccades in both horizontal directions. no vertical gaze abnormalities noted. infrequent spontaneous forehead wrinkling and mouth movements. the rest of the cn exam was unremarkable. motor: full strength throughout and normal muscle tone and bulk. mild choreiform movements were noted in the hands and feet. sensory: unremarkable. coord: unremarkable. station/gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of bue became more apparent. reflexes: 2/2 throughout. plantar responses were flexor, bilaterally. there was no motor impersistence on tongue protrusion or hand grip. course: he was thought to have early manifestations of huntington disease. a hct was unremarkable. elavil 25mg qhs was prescribed. neuropsychologic assessment revealed mild anterograde memory loss only. his chorea gradually worsened during the following 4 years. he developed motor impersistence and more prominent slowed saccadic eye movements. his mood/affect became more labile. 6/5/96 genetic testing revealed a 45 cag trinucleotide repeat band consistent with huntington disease. mri brain, 8/23/96, showed caudate nuclei atrophy, bilaterally."
+"cardiolite treadmill exercise stress test clinical data:  this is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block. procedure:  the patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 mets.  there was a normal blood pressure response.  the patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed. myocardial perfusion imaging was performed at rest following the injection of 10 mci tc-99 cardiolite.  at peak pharmacological effect, the patient was injected with 30 mci tc-99 cardiolite. gating poststress tomographic imaging was performed 30 minutes after the stress.findings:1.  the overall quality of the study is fair.2.  the left ventricular cavity appears to be normal on the rest and stress studies.3.  spect images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.4.  the left ventricular ejection fraction was normal and estimated to be 78%. impression:  myocardial perfusion imaging is normal.  result of this test suggests low probability for significant coronary artery disease."
+"history of present illness:  briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  he is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality. procedure performed:  egd. prep:  cetacaine spray, 100 mcg of fentanyl iv, and 5 mg of versed iv. findings:  the tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  there were come concentric rings present.  there was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  there was no stricture or barrett mucosa.  the bony and the antrum of the stomach are normal without any acute peptic lesions.  retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  there were no acute lesions and no evidence of ulcer, tumor, or polyp.  the pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  adverse reactions:  none. final impression:  esophageal changes suggestive of eosinophilic esophagitis.  biopsies throughout the length of the esophagus were obtained for microscopic analysis.  there was no evidence of stricture, barrett, or other abnormalities in the upper gi tract."
+a 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator. comparison studies: none. medication:   lopressor 5 mg iv. heart rate after medication: 64bpm exam:technique: tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc
+"<strong>preoperative diagnosis: </strong>history of polyps. <strong>postoperative diagnoses:</strong> 1. normal colonoscopy, left colonic diverticular disease. 2. 3+ benign prostatic hypertrophy. <strong>procedure performed: </strong>total colonoscopy and photography. <strong>gross findings: </strong>this is a 74-year-old white male here for recheck colonoscopy for a history of polyps. after signed informed consent, blood pressure monitoring, ekg monitoring, and pulse oximetry monitoring, he was brought to the endoscopic suite. he was given 100 mg of demerol, 3 mg of versed iv push slowly. digital examination revealed a large prostate for which he is following up with his urologist. no nodules. 3+ bph. anorectal canal was within normal limits. no stricture tumor or ulcer. the olympus cf 20l video endoscope was inserted per anus. the anorectal canal was visualized, was normal. the sigmoid, descending, splenic, and transverse showed scattered diverticula. the hepatic, ascending, cecum, and ileocecal valve was visualized and was normal. the colonoscope was removed. the air was aspirated. the patient was discharged with high-fiber, diverticular diet. recheck colonoscopy three years."
+"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 &quot;normal&quot; 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 &quot;up to date.&quot; 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."
+"your patient, (abc), a 59-year-old female with no known coronary artery disease was referred to us for a ct coronary angiogram.  the patient&#8217;s cardiac risk factors include chest discomfort, family history of coronary artery disease, and hypercholesterolemia.  she is on no cardiac medications at the time of testing.  the patient&#8217;s resting ecg demonstrated no ischemic changes. cardiac ct including coronary ct angiography procedure:  breath hold cardiac ct was performed using a 64-channel ct scanner with a 0.5-second rotation time.  contrast injection was timed using a 10 ml bolus of ultravist 370 iv.  then the patient received 75 ml of ultravist 370 at a rate of 5 ml/sec. retrospective ecg gating was performed.  the patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  the average heart rate was 62 beats/min. the patient had no adverse reaction to the contrast.  multiphase retrospective reconstructions were performed.  small field of view cardiac and coronary images were analyzed on a 3d work station.  multiplanar reformatted images and 3d volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease. coronary cta:1.  the technical quality of the scan is adequate.2.  the coronary ostia are in their normal position.  the coronary anatomy is right dominant.3.  left main:  the left main coronary artery is patent without angiographic stenosis.4.  left anterior descending artery:  the proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.5.  the ramus intermedius is a small vessel with minor irregularities.6.  left circumflex:  the left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.7.  right coronary artery:  the right coronary artery is a large and dominant vessel.  it demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  left ventricular ejection fraction is calculated to be 69%.  there are no wall motion abnormalities.8.  coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels. ancillary findings:  none. final impression:1.  mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.2.  recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy. thank you for referring this patient to us."
+"procedures:1.  right and left heart catheterization.2.  coronary angiography.3.  left ventriculography. procedure in detail:  after informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  patient was prepped and draped in sterile fashion.  via modified seldinger technique, the right femoral vein was punctured and a 6-french sheath was placed over a guide wire.  via modified seldinger technique, right femoral artery was punctured and a 6-french sheath was placed over a guide wire.  the diagnostic procedure was performed using the jl-4, jr-4, and a 6-french pigtail catheter along with a swan-ganz catheter.  the patient tolerated the procedure well and there were immediate complications were noted.  angio-seal was used at the end of the procedure to obtain hemostasis. coronary arteries: left main coronary artery:  the left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  no significant stenotic lesions were identified in the left main coronary artery. left anterior descending coronary artery:  the left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  no significant stenotic lesions were identified in the left anterior descending coronary artery system. circumflex artery:  the circumflex artery is a moderate sized vessel.  the vessel is a stenotic lesion.  after the right coronary artery, the rca is a moderate size vessel with no focal stenotic lesions. hemodynamic data:  capital wedge pressure was 22.  the aortic pressure was 52/24.  right ventricular pressure was 58/14.  ra pressure was 14.  the aortic pressure was 127/73.  left ventricular pressure was 127/15.  cardiac output of 9.2. left ventriculogram:  the left ventriculogram was performed in the rao projection only.  in the rao projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  severe mitral regurgitation was also noted. impression:1.  left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.2.  severe mitral regurgitation.3.  no significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery."
+"preoperative diagnosis:  atelectasis. postoperative diagnosis:  mucous plugging. procedure performed:  bronchoscopy. anesthesia:  lidocaine topical 2%, versed 3 mg iv.  conscious sedation. procedure:  at bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  the main carina was visualized.  the trachea was free of any secretions.  the right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  left mainstem appeared patent.  left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  the area was lavaged with some saline and cleared.  the patient tolerated the procedure well."
+"preoperative diagnoses:  progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function. postoperative diagnoses:  progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function. operative procedure:  coronary artery bypass grafting (cabg) x4. grafts performed:  lima to lad, left radial artery from the aorta to the pda, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal. indications for procedure:  the patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina.  he had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved lv function.  he was advised surgical revascularization of his coronaries. findings during the procedure:  the aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp.  left internal mammary artery and saphenous vein grafts were good quality conduits.  radial artery graft was a smaller sized conduit, otherwise good quality.  all distal targets showed heavy plaque involvement with calcification present.  the smallest target was the pda, which was about 1.5 mm in size.  all the other targets were about 2 mm in size or greater.  the patient came off cardiopulmonary bypass without any problems.  he was transferred on neo-synephrine, nitroglycerin, precedex drips.  cross clamp time was 102 minutes, bypass time was 120 minutes. details of the procedure:  the patient was brought into the operating room and laid supine on the table.  after he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right ij triple-lumen catheter and cordis catheter, right radial a-line, foley catheter, tee probes were placed and interfaced appropriately.  the patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion.  preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest. after prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed.  left internal mammary artery was taken down.  simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques.  simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques.  subsequent to harvest, the incisions were closed in layers during the course of the procedure. heparin was given.  pericardium was opened and suspended.  during the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally.  only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery. pericardium was opened and suspended.  pursestring sutures were placed.  aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass.  with satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia.  an initial dose of about 1500 ml was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart. pda was exposed first.  the right coronary artery was calcified along its course all the way to its terminal bifurcation.  even in the pda, calcification was noted in a spotty fashion.  arteriotomy on the pda was performed in a soft area and 1.5 probe was noted to be accommodated in both directions.  end radial to side pda anastomosis was constructed using running 7-0 prolene.  next, the posterolateral obtuse marginal was exposed.  arteriotomy was performed.  an end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 prolene.  this graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 prolene.  next, a slit was made in the left side of the pericardium and lima was accommodated in the slit on its way to the lad.  lad was exposed.  arteriotomy was performed.  an end lima to side lad anastomosis was constructed using running 7-0 prolene.  lima was tacked down to the epicardium securely utilizing its fascial pedicle. two stab incisions were made in the ascending aorta and enlarged using 4-mm punch.  two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 prolene.  the patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed.  following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity.  temporary v-pacing wires were placed.  blake drains were placed in the left chest, the right chest, as well as in the mediastinum.  left chest blake drain was placed just in the medial section where dissection had been performed.  after an adequate period of rewarming during which time, temporary v-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems.  with satisfactory hemodynamics, good lv function on tee and baseline ekg, heparin was reversed using protamine.  decannulation was performed after volume resuscitation.  hemostasis was assured.  mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy vicryl for musculofascial closure, and monocryl for subcuticular skin closure.  dressings were applied.  the patient was transferred to the icu in stable condition.  he tolerated the procedure well.  all counts were correct at the termination of the procedure.  cross clamp time was 102 minutes.  bypass time was 120 minutes.  the patient was transferred on neo-synephrine, nitroglycerin, and precedex drips."
+"chief complaint:  the patient is a 49-year-old caucasian male transported to the emergency room by his wife, complaining of shortness of breath. history of present illness: the patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. he has made multiple visits in the past. today, the patient presents himself in severe respiratory distress. his wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath. today, his symptoms worsened and she brought him to the emergency room. to the best of her knowledge, there has been no fever. he has persistent chronic cough, as always. more complete history cannot be taken because of the patient"
+"ct abdomen with contrast and ct pelvis with contrast reason for exam:  generalized abdominal pain with swelling at the site of the ileostomy. technique:  axial ct images of the abdomen and pelvis were obtained utilizing 100 ml of isovue-300. ct abdomen:  the liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  punctate calcifications in the gallbladder lumen likely represent a gallstone. ct pelvis:  postsurgical changes of a left lower quadrant ileostomy are again seen.  there is no evidence for an obstruction.  a partial colectomy and diverting ileostomy is seen within the right lower quadrant.  the previously seen 3.4 cm subcutaneous fluid collection has resolved.  within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  this is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  no obstruction is seen.  the appendix is not clearly visualized.  the urinary bladder is unremarkable. impression:1.  resolution of the previously seen subcutaneous fluid collection.2.  left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  these findings may be due to a pelvic abscess.3.  right lower quadrant ileostomy has not significantly changed.4.  cholelithiasis."
+"preoperative diagnosis:  history of colitis. postoperative diagnosis:  small left colon polyp. procedure performed:  total colonoscopy and polypectomy. anesthesia:  iv versed 8 mg and 175 mcg of iv fentanyl. clinical history:  this patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding.  he has been admitted to the hospital now for colonoscopy and polyp surveillance. procedure:  the patient was prepped and draped in a left lateral decubitus position.  the flexible 165 cm cf video olympus colonoscope was inserted through the anus and passed under tv-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum.  he had an excellent prep.  he had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps.  he tolerated the procedure well.  there was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon.  his exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since.  representative pictures were taken throughout the entire exam.  there was no other evidence any problems.  on withdrawal of the scope, the same findings were noted. final impression:  small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding."
+"preoperative diagnosis:  coronary artery disease. postoperative diagnosis:  coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis. description of procedure:left heart catheterization with angiography and mid abdominal aortography:under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  using the percutaneous seldinger technique via the right femoral artery, a left heart catheterization was performed.  coronary arteriography was performed with 6-french performed coronary catheters.  we used a 6-french jr4 and jl4 catheters to take multiple cineangiograms of the right and left coronary arteries.  after using the jr4 6-french catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-french jr4 catheter for additional cineangiograms of the right coronary artery.  a pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta. analysis of pressure data:  left ventricular end-diastolic pressure was 5 mmhg.  on continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  the aortic pressures were normal.  contours of intracardiac pressure were normal. analysis of angiograms:  selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  a pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  the mitral valve is competent and demonstrates normal mobility.  the left ventricular cavity is normal in size with excellent contractility.  aneurysmal dilatation and/or dyskinesia absent.  the aortic valve is tricuspid and normal mobility.  the ascending aorta appeared normal. pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  an abdominal aortic injection was performed.  under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  there was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  the abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  there is a normal left renal artery, normal right renal artery.  the celiac seems to be normal, but what i believe is the splenic artery seen initially at its origin is normal.  the common left iliac and common right iliac arteries are essentially normal in this area. coronary anatomy:  one notes ostial coronary calcification of the right coronary artery.  cineangiogram obtained with 6-french jr4 and 5-french jr4 catheters.  prior to the introduction of the 5-french jr4 nitroglycerin was administered sublingually.  the 6-french jr4 catheters appeared to a show an ostial lesion of over 50%.  there was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  in the proximal portion of the right coronary artery just into the shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  the distal portion of the vessel is free of disease.  the conus branch is seen arising right at the beginning part of the right coronary artery.  we then removed the 6-french catheter and following nitroglycerin and sublingually we placed a 5-french catheter and again finding a stenosis, may be less than 50%.  at the ostium of the right coronary artery, calcification again is identified.  backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the shepherd turn area. the left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  it forms the left anterior descending artery, the ramus branch, and the circumflex artery. the left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  there appears to be some mild stenosis of 10% in the proximal segment.  it gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  the remaining portion of the left anterior descending artery is free of disease.  upon injection of the left coronary artery, we see what i believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  i could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place. the ramus branch is normal and free of disease. the left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease. the patient has a predominantly right coronary system.  there is no _______ circulation connecting the right and left coronary systems. the patient tolerated the procedure well.  the catheter was removed.  hemostasis was achieved.  the patient was transferred to the recovery room in a stable condition. impression:1.  excellent left ventricular contractility with normal left ventricular cavity size.2.  calcification of the mid abdominal aorta with wide patency of all vessels.  the left and right renal arteries are normal.  the external iliac arteries are normal.3.  essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.4.  ostial stenosis of the right coronary artery that appears to be about 50% or greater.  the proximal right coronary artery has 50% stenosis as well.5.  coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries. recommendations:  the patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  the ostial lesion of the right coronary artery may be severe.  it is at least 50%, but it could be worse.  therefore, she will be evaluated for the possibility of an ivus and/or _______ analysis of the proximal right coronary artery.  we will reevaluate her stress nuclear study as well.  continue aggressive medical therapy."
+"indication:  iron deficiency anemia. procedure:  colonoscopy with terminal ileum examination. postoperative diagnosis:  normal examination. withdrawal time:  15 minutes. scope:  cf-h180al. medications:  fentanyl 100 mcg and versed 10 mg. procedure detail:  following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  questions were answered.  pause preprocedure was performed. following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  the ileocecal valve looked normal.  preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  the terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  terminal ileum mucosa looked normal. then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  no polyp, no diverticulum and no bleeding source was identified. the patient was assessed upon completion of the procedure.  okay to discharge once criteria met.   recommendations:  follow up with primary care physician."
+"problems list:1.  type 1 diabetes mellitus, insulin pump requiring.2.  chronic kidney disease, stage iii.3.  sweet syndrome.4.  hypertension.5.  dyslipidemia.6.  osteoporosis.7.  anemia.8.  a 25-hydroxy-vitamin d deficiency.9.  peripheral neuropathy manifested by insensate feet.10.  hypothyroidism.11.  diabetic retinopathy. history of present illness:  this is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  her last visit to this clinic was approximately three months ago.  since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  she did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  her 14-day average is 191.  she had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  she was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  she was able to manage this completely on her own.  in the meantime, she is not having any other medical problems that have interfered with glucose control.  her diet has been a little bit different in that she had been away visiting with her family for some period of time as well. current medications:1.  a number of topical creams for her rash.2.  hydroxyzine 25 mg 4 times a day.3.  claritin 5 mg a day.4.  fluoxetine 20 mg a day.5.  ergocalciferol 800 international units a day.6.  protonix 40 mg a day.7.  iron sulfate 1.2 cc every day.8.  actonel 35 mg once a week.9.  zantac 150 mg daily.10.  calcium carbonate 500 mg 3 times a day.11.  novolog insulin via insulin pump about 30 units of insulin daily.12.  zocor 40 mg a day.13.  valsartan 80 mg daily.14.  amlodipine 5 mg a day.15.  plavix 75 mg a day.16.  aspirin 81 mg a day.17.  lasix 20 mg a day.18.  levothyroxine 75 micrograms a day. review of systems:  really not much change.  her upper respiratory symptoms have resolved.  she is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  she is not having any decreased appetite.  she is not having painful urination, any blood in the urine, frequency or hesitancy.  she is not having polyuria, polydipsia or polyphagia.  her visual acuity has declined, but she does not appear to have any acute change. physical examination:vital signs:  temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  heent:  examination found her to be atraumatic and normocephalic.  she has pupils that are equal, round, and reactive to light.  extraocular muscles intact.  sclerae and conjunctivae are clear.  the paranasal sinuses are nontender.  the nose is patent.  the external auditory canal and tympanic membranes are clear a.u.  oral cavity and oropharynx examination is free of lesions.  the mucosus membranes are moist.  neck:  supple.  there is no lymphadenopathy.  there is no thyromegaly.  thorax:  reveals lungs that are clear, pa and lateral, without adventitious sounds.  cardiovascular:  demonstrated regular rate and rhythm.  extremities:  reveal no edema and is otherwise deferred. assessment and plan:  this is a return visit to the renal clinic for the patient with history as noted above.  she has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  her target pre-meal is 120 and bedtime is 150.  her insulin/carbohydrate ratio is 10 and her correction factor is 60.  we are not going to make any changes to her insulin pump settings at this time.  i have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  she has agreed to try that and cut back on this a little bit.  i want to get fasting labs to include her standard labs for us today but include a fasting c-peptide and a hemoglobin a1c, so that we can make arrangements for her to get an upgraded insulin pump.  she states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  nonetheless, she is out of warranty and we will try to get her a new pump. plan to see the patient back here in approximately two months, and we will try to get the new pump through medicare."
+"preoperative diagnoses1.  dyspnea on exertion with abnormal stress echocardiography.2.  frequent pvcs.3.  metabolic syndrome. postoperative diagnoses1.  a 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.2.  frequent pvcs.3.  metabolic syndrome. procedures1.  left heart catheterization with left ventriculography.2.  selective coronary angiography. complications:  none. description of procedure:  after informed consent was obtained, the patient was brought to the cardiac catheterization laboratory in fasting state.  both groins were prepped and draped in the usual sterile fashion.  xylocaine 1% was used as local anesthetic.  versed and fentanyl were used for conscious sedation.  next, a #6-french sheath was placed in the right femoral artery using modified seldinger technique.  next, selective angiography of the left coronary artery was performed in multiple views using #6-french jl4 catheter.  next, selective angiography of the right coronary artery was performed in multiple views using #6-french 3drc catheter.  next, a #6-french angle pigtail catheter was advanced into the left ventricle.  the left ventricular pressure was then recorded.  left ventriculography was the performed using 36 ml of contrast injected over 3 seconds.  the left heart pull back was then performed.  the catheter was then removed. angiography of the right femoral artery was performed.  hemostasis was obtained by angio-seal closure device.  the patient left the cardiac catheterization laboratory in stable condition. hemodynamics1.  lv pressure was 163/0 with end-diastolic pressure of 17.  there was no significant gradient across the aortic valve.2.  left ventriculography showed old inferior wall hypokinesis.  global left ventricular systolic function is normal.  estimated ejection fraction was 58%.  there is no significant mitral regurgitation.3.  significant coronary artery disease.4.  the left main is approximately 7 or 8 mm proximally.  it trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  the distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.5.  the left anterior descending artery is around 4 mm proximally.  it extends slightly beyond the apex into the inferior wall.  it gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  at the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow lao with caudal angulation. there was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches. the ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  there was no significant disease noted in the ramus intermedius artery however. the left circumflex artery is around 2.5 mm proximally.  it gave off a recurrent atrial branch and a small av groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  the mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%. the right coronary artery is around 4 mm in diameter.  it gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  in the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  the posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment. plan:  plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  continue risk factor modification, aspirin, and beta blocker."
+"preoperative diagnoses1.  bilateral bronchopneumonia.2.  empyema of the chest, left. postoperative diagnoses1.  bilateral bronchopneumonia.2.  empyema of the chest, left. procedures1.  diagnostic bronchoscopy.2.  limited left thoracotomy with partial pulmonary decortication and insertion of chest tubes x2. description of procedure:  after obtaining an informed consent, the patient was taken to the operating room where a time-out process was followed.  initially, the patient was intubated with a #6 french tube because of the presence of previous laryngectomy.  because of this, i proceeded to use a pediatric bronchoscope, which provided limited visualization, but i was able to see the trachea and the carina and both left and right bronchial systems without significant pathology, although there was some mucus secretion that was aspirated. then, with the patient properly anesthetized and looking very stable, we decided to insert a larger endotracheal tube that allowed for the insertion of the regular adult bronchoscope.  therefore, we were able to obtain a better visualization and see the trachea and the carina that were normal and also the left and right bronchial systems.  some brownish secretions were obtained, particularly from the right side and were sent for culture and sensitivity, both aerobic and anaerobic fungi and acid fast. then, the patient was turned with left side up and prepped for a left thoracotomy.  he was properly draped.  i had recently re-inspected the ct of the chest and decided to make a limited thoracotomy of about 6 cm or so in the midaxillary line about the sixth intercostal space.  immediately, it was evident that there was a large amount of pus in the left chest.  we proceeded to insert the suction catheters and we rapidly obtained about 1400 ml of frank pus.  then, we proceeded to open the intercostal space a bit more with a richardson retractor and it was immediately obvious that there was an abundant amount of solid exudate throughout the lung.  we spent several minutes trying to clean up this area.  initially, i had planned only to drain the empyema because the patient was in a very poor condition, but at this particular moment, he was more stable and well oxygenated, and the situation was such that we were able to perform a partial pulmonary decortication where we broke up a number of loculations that were present and we were able to separate the lung from the diaphragm and also the pulmonary fissure.  on the upper part of the chest, we had limited access, but overall we obtained a large amount of solid exudate and we were able to break out loculations.  we followed by irrigation with 2000 cc of warm normal saline and then insertion of two #32 chest tubes, which are the largest one available in this institution; one we put over the diaphragm and the other one going up and down towards the apex. the limited thoracotomy was closed with heavy intercostal sutures of vicryl, then interrupted sutures of #0 vicryl to the muscle layers, and i loosely approximately the skin with a few sutures of nylon because i am suspicious that the incision may become infected because he has been exposed to intrapleural pus. the chest tubes were secured with sutures and then connected to pleur-evac.  then, the patient was transported. estimated blood loss was minimal and the patient tolerated the procedure well.  he was extubated in the operating room and he was transferred to the icu to be admitted.  a chest x-ray was ordered stat."
+"the patient is being discharged for continued hemodialysis and rehab. discharge diagnoses:1.  end-stage renal disease, on hemodialysis.2.  history of t9 vertebral fracture.3.  diskitis.4.  thrombocytopenia.5.  congestive heart failure with ejection fraction of approximately 30%.6.  diabetes, type 2.7.  protein malnourishment.8.  history of anemia. history and hospital course:  the patient is a 77-year-old white male who presented to hospital of bossier on april 14, 2008.  the patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  he also needed to continue with dialysis and he needed to improve his rehabilitation.  the patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  he did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  the patient had remained afebrile.  he did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at promise.  on the day of discharge, on may 9, 2008, the patient was in good spirits, was very clear and lucid.  he denied any complaints of pain.  he did have some trouble with sleep at night at times, but i think this was mainly tied into the fact that he sleeps a lot during the day.  the patient has increased his appetite some and has been eating some.  his vital signs remain stable.  his blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  ppd was negative.  an sms form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at promise. the patient and his family understood our plan and agreed with it.  he thanked us for the care that he received at promise and thought that they did a fantastic job taking care of him.  he did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge."
+"<strong>history:</strong> this is a digital eeg performed on a 75-year-old male with seizures. <strong>background activity:</strong> the background activity consists of a 8 hz to 9 hz rhythm arising in the posterior head region. this rhythm is also accompanied by some beta activity which occurs infrequently. there are also muscle contractions occurring at 4 hz to 5 hz which suggests possible parkinson&#8217;s. part of the eeg is obscured by the muscle contraction artifact. there are also left temporal sharps occurring infrequently during the tracing. at one point of time, there was some slowing occurring in the right frontal head region. <strong>activation procedures:</strong> photic stimulation was performed and did not show any significant abnormality. <strong>sleep patterns:</strong> no sleep architecture was observed during this tracing. <strong>impression:</strong> this awake/alert/drowsy eeg is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. the slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. the tremor probably represents a parkinson&#8217;s tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended."
+"preoperative diagnosis:  coronary occlusive disease. postoperative diagnosis:  coronary occlusive disease. operation procedure:  coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal.  total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection. indication for the procedure:  the patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%. findings:  the lad was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good. description of procedure:  the patient was brought to the operating room and placed in the supine position.  adequate general endotracheal anesthesia was induced.  appropriate monitoring devices were placed.  the chest, abdomen and legs were prepped and draped in the sterile fashion.  the right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 surgilon and flushed with heparinized blood.  hemostasis was achieved in the legs and closed with running 2-0 dexon in the subcutaneous tissue and running 3-0 dexon subcuticular in the skin.median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  the pericardium was opened.  the pericardial cradle was created.  the patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  a retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 prolene suture in the right atrial wall into the coronary sinus and tied to a rumel tourniquet.  an antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 prolene.  cardiopulmonary bypass was instituted and the ascending aorta was crossclamped.  antegrade cardioplegia was given at a total of 5 ml per kg through the aortic route.  this was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 ml per kg.  the obtuse marginal coronary was identified and opened. end-to-side anastomosis was performed with a running 7-0 prolene suture and the vein was cut to length.  cold antegrade and retrograde potassium cardioplegia were given.  the mammary artery was clipped distally, divided and spatulated for anastomosis.  the anterior descending was identified and opened.  end-to-side anastomosis was performed with running 8-0 prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed.  the partial occlusion clamp was placed.  aortotomies were made.  the veins were cut to fit these and sutured in place with running 5-0 prolene suture.  a partial occlusion clamp was removed.  all anastomoses were inspected and noted to be patent and dry.  ventilation was commenced.  the patient was fully warm and the patient was then wean from cardiopulmonary bypass.  the patient was decannulated in 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 plus two 5-mm mersiline tapes. the linea alba was closed with figure-of-eight of #1 vicryl, the sternal fascia closed with running #1 vicryl, the subcu closed with running 2-0 dexon, skin with running 4-0 dexon subcuticular stitch.  the patient tolerated the procedure well."
+"chief reason for consultation:  evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal ekg. history of present illness:  this 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  during this time, patient felt extremely short of breath and dizzy.  palpitations lasted for about five to ten minutes without any recurrence.  patient also gives history of having tightness in the chest after she walks briskly up to a block.  chest tightness starts in the retrosternal area with radiation across the chest.  chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  patient gives history of having hypertension for the last two months.  patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident. medications:  1.  astelin nasal spray.2.  evista 60 mg daily.3.  lopressor 25 mg daily.4.  patient was given a sample of diovan 80 mg daily for the control of hypertension from my office. past history:  the patient underwent right foot surgery and c-section. family history:  the patient is married, has six children who are doing fine.  father died of a stroke many years ago.  mother had arthritis. social history: the patient does not smoke or take any drinks.   allergies:  the patient is not allergic to any medications. review of systems:  otherwise negative.   physical examination:  general:  well-built, well-nourished white female in no acute distress. vital signs:  blood pressure is 160/80.  respirations 18 per minute.  heart rate 70 beats per minute.  patient weighs 133 pounds, height 64 inches.  bmi is 22.heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good.neck:  supple.  no cervical lymphadenopathy. carotid upstroke is good. no bruit heard over the carotid or subclavian arteries.  trachea in midline. thyroid not enlarged.  jvp flat at 45&deg;.chest:  chest is symmetrical on both sides, moves well with respirations.  vesicular breath sounds heard over the lung fields.  no wheezing, crepitation, or pleural friction rub heard.  cardiovascular system:  pmi felt in fifth left intercostal space within midclavicular line. first and second heart sounds are normal in character.  there is a ii/vi systolic murmur best heard at the apex.  there is no diastolic murmur or gallop heard.abdomen:  soft.  there is no hepatosplenomegaly or ascites.  no bruit heard over the aorta or renal vessels.extremities:  no pedal edema.  femoral arterial pulsations are 3+, popliteal 2+.  dorsalis pedis and posterior tibialis are 1+ on both sides.neuro:  normal. ekg from dr. xyz&#8217;s office shows normal sinus rhythm, st and t wave changes.  lipid profile, random blood sugar, bun, creatinine, cbc, and lfts are normal. impression:   1.  exercise-induced chest pain.2.  palpitations with dizziness.3.  abnormal ekg.4.  hypertension.5.  heart murmur. plan:  1.  adenosine myoview spect, 24-hour holter monitor, echocardiogram.2.  carotid ultrasound.3.  micro-t wave alternans test.4.  diovan 80 mg has been given to the patient from our sample closet for the control of hypertension.5.  patient will be seen again in my office in two weeks."
+"reason for visit:  ms. abc is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation.  she comes to clinic by herself. history of present illness:  she has been followed for her hydrocephalus since 2002.  she also had an anterior cervical corpectomy and fusion from c3 though c5 in march 2007.  she was last seen by us in clinic in march 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0.  we wanted her to followup with dr. xyz regarding the mri of the cervical spine.  today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes.  she reports no urgency, incontinence, and feels that she completely empties her bladder when she goes.  she does experience some leakage with coughing.  she wears the pad on a daily basis.  she does not think that her bladder has changed much since we saw her last.  with respect to her thinking and memory, she reports no problems at this time.  she reports no headaches at this time.  with respect to her walking and balance, she says that it feels worse.  in the beginning of may, she had a coughing spell and at that time she developed buttock pain, which travels down the legs.  she states that her leg often feel like elastic and she experiences a tingling radiculopathy.  she says that this tingling is constant and at times painful.  she feels that she is walking slower for this reason.  she does not use the cane at this time.  most of the time, she is able to walk over uneven surfaces.  she is able to walk up and down stairs and has no trouble getting in and out of a car. medications:  rhinocort 32 mg two sprays a day, singulair 10 mg once a day, xyzal 5 mg in the morning, spiriva once a day, advair twice a day, prevacid 30 mg twice a day, os-cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day. major findings:  on exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty.  she is well developed, well nourished, and kempt. the shunt site is clean, dry, and intact and confirmed at a setting of 1.0. mental status:  assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  her mini-mental status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling. cranial nerves:  extraocular movements are somewhat inhibited.  she does not display any nystagmus at this time.  facial movement, hearing, head turning, tongue, and palate movement are all intact. gait:  assessed using the tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28. assessment:  ms. abc has been experiencing difficulty with walking over the past several months. problems/diagnoses:1.  hydrocephalus.2.  cervical stenosis and retrolisthesis.3.  neuropathy in the legs. plan:  before we recommend anything more, we would like to get a hold of the notes from dr. xyz to try to come up with a concrete plan as to what we can do next for ms. abc.  we believe that her walking is most likely not being effected by the hydrocephalus.  we would like to see her back in clinic in two and a half months or so.  we also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one.  i suggested that she use the cane at her on discretion."
+"indications:  predominant rhythm is sinus.  heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute.  minimum heart rate of 50 beats per minute. 640 ventricular ectopic isolated beats noted.  rare isolated apcs and supraventricular couplets. one supraventricular triplet reported. triplet maximum rate of 178 beats per minute noted."
+"reason for consultation:  atrial fibrillation management. history of present illness: the patient is a very pleasant 62-year-old african american female with a history of hypertension, hypercholesterolemia, and cva, referred by dr. x for evaluation and management of atrial fibrillation.  the patient states that on monday during routine holt exam, it was detected by dr. x that her heart was irregular on exam.  ekg obtained after that revealed atrial fibrillation, and subsequently the patient was started on coumadin as well as having toprol and referred for evaluation.  the patient states that for the last 3 years, she has had episodes of her heart racing.  it may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  they subsequently resolve on their own and do not limit her in anyway.  however, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  she said she can walk no more than 25 feet without becoming tired.  she states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  denies peripheral edema, pnd, orthopnea, abdominal pain, swelling, recent fever or chills.  she actually today has no complaints, and states that she has been compliant with her medications and has started taking her coumadin as directed. past medical history:1.  hypertension.2.  myocardial infarction in 2003.3.  left heart catheterization at university hospital.4.  hypercholesterolemia.5.  arthritis.6.  cva in 2002 and in 2003 with right eye blindness. past surgical history:1.  left total knee replacement in 2002.2.  left lower quadrant abscess drainage in 12/07 family medical history:  significant for lung and brain cancer.  there is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death. social history:  she is retired as a cook in a school cafeteria, where she worked for 34 years.  she retired 7 years ago because of low back pain.  she used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  denies alcohol, and denies iv or illicit drug use. allergies:  no known drug allergies. medications:1.  coumadin 5 mg a day.2.  toprol-xl 50 mg a day.3.  aspirin 81 mg a day.4.  hydrochlorothiazide 25 mg a day.5.  plendil 10 mg daily.6.  lipitor 40 mg daily. review of systems:  as above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery. physical examination:vital signs:  blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  general:  a well-developed, well-nourished, middle-aged african american female in no acute distress.  neck:  supple.  no jvd.  no carotid bruits.  cardiovascular:  irregularly irregular rate and rhythm.  normal s1 and s2.  no murmurs, gallops or rubs.  lungs:  clear to auscultation bilaterally.  abdomen:  bowel sounds positive, soft, nontender, and nondistended.  no masses.  extremities:  no clubbing, cyanosis or edema.  pulses 2+ bilaterally. laboratory data:  ekg today revealed atrial fibrillation with nonspecific lateral t-wave abnormalities and a rate of 94. impression:  the patient is a very pleasant 62-year-old african american female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today. recommendations:1.  her rate is suboptimally controlled, we will increase her toprol-xl to 75 mg per day.2.  we will obtain a transthoracic echocardiogram to evaluate her lv function as well as her valvular function.3.  we will check a thyroid function panel.4.  we will continue coumadin as directed and to follow up with dr. x for inr management.5.  given the patient&#8217;s history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on coumadin indefinitely.6.  depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  we will await results of transthoracic echocardiogram.7.  we will arrange for the patient to wear a holter monitor to monitor the rate controlled on a 24-hour period.  she will then return to the electrophysiology clinic in 1 month for followup visit with dr. y. the patient was seen, discussed, and examined with dr. y in electrophysiology."
+"preoperative diagnosis:  carcinoma of the left upper lobe. procedures performed:1.  bronchoscopy with aspiration.2.  left upper lobectomy. procedure details:  with patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  the carina was in the midline and sharp.  moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  aspiration was carried out for backlog ________ examination.  we then moved to left side, left upper lobe.  there was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  no anatomic lesions were demonstrated.  the patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an ng tube and a foley catheter.  after proper position, utilizing betadine solution, they were draped.  a posterolateral left thoracotomy incision was performed.  hemostasis was secured with electrocoagulation.  the chest wall muscle was then divided over the sixth rib.  the periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  at this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  we examined the superior mediastinum.  no lymph nodes were demonstrated as well as in the anterior mediastinum.  direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  casual dissection was carried out with superior segmental arteries and left lower lobe was examined. dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  from the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  tumor mass was close to the artery at this time.  we then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  the posterior artery of the superior branch was doubly ligated and cut free also.  at this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  we then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  using the ta 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  a potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  the anterior artery was seen in the clamp also and was separated and ligated and separated.  at this time, the entire tumor in the left upper lobe was then removed.   direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  the clamp was then removed.  no bleeding was seen at this time.  lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  we then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  at this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  the chest cavity was then closed.  after reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  a #2-0 polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  the chest tubes were attached to the pleur-evac drainage and placed on suction at this time.  the patient was extubated in the room without difficulty and sent to recovery in satisfactory."
+"dear dr. cd: please accept this letter of follow up on patient xxx xxx. he is now three months out from a left carotid angioplasty and stent placement. he was a part of a capsure trial. he has done quite well, with no neurologic or cardiac event in the three months of follow up. he had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence. sincerely, xyz, md"
+"sample doctor, m.d.sample address re:  mrs. sample patient dear sample doctor: i had the pleasure of seeing your patient, mrs. sample patient , in my office today.  mrs. sample patient is a 48-year-old, african-american female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  the patient denies any weight loss, does have a good appetite, no nausea and no vomiting. past medical history:  significant for hypertension and diabetes. past surgical history:  the patient denies any past surgical history. medications:  the patient takes cardizem cd 240-mg.  the patient also takes eye drops. allergies:  the patient denies any allergies. social history:  the patient smokes about a pack a day for more than 25 years.  the patient drinks alcohol socially. family history:  significant for hypertension and strokes. review of systems:  the patient does have a good appetite and no weight loss.  she does have intermittent rectal bleeding associated with irritation in the rectal area.  the patient denies any nausea, any vomiting, any night sweats, any fevers or any chills. the patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough. the patient is chronically constipated. physical examination:  this is a 48 year-old lady who is awake, alert and oriented x 3.  she does not seem to be in any acute distress.  her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  heent is normocephalic, atraumatic.  sclerae are non-icteric.  her neck is supple, no bruits, no lymph nodes.  lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  the cardiovascular system has a regular rate and rhythm, no murmurs.  the abdomen is soft and non-tender.  bowel sounds are positive and no organomegaly.  extremities have no edema. impression:  this is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  the patient is chronically constipated.1.  rule out colon cancer.2.  rule out colon polyps. 3.  rule out hemorrhoids, which is the most likely diagnosis. recommendations:  because of the patient&#8217;s age, the patient will need to have a complete colonoscopy exam. the patient will also need to have a cbc check and monitor. the patient will be scheduled for the colonoscopy at sample hospital and the full report will be forwarded to your office. thank you very much for allowing me to participate in the care of your patient. sincerely yours, sample doctor, md"
+"operative procedure:1.  redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.2.  placement of a right femoral intraaortic balloon pump. description:  the patient was brought to the operating room and placed in the supine position.  after adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  chest, abdomen an legs were prepped and draped in sterile fashion.  the femoral artery on the right was punctured and a guidewire was placed.  the track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started. the left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  the leg was closed with running 3-0 dexon subcu and running 4-0 dexon on the skin. the old mediastinal incision was opened.  the wires were cut and removed.  the sternum was divided in the midline.  retrosternal attachments were taken down.  the left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  the heart was dissected free of its adhesions.  the patient was fully heparinized and cannulated with a single aorta and single venous cannula.  retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 prolene.  an antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  cardiopulmonary bypass ensued.  the ascending aorta was cross clamped.  cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  it was followed by sumping the ascending aorta.  the obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 prolene suture.  the vein was cut to length.  antegrade cardioplegia was given, a total of 200 cc.  the posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 prolene suture.  the vein was cut to length.  antegrade cardioplegia was given.  the mammary was clipped distally, divided and spatulated for anastomosis.  the anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 prolene suture and warm blood potassium cardioplegia was given.  the cross clamp was removed.  a partial-occlusion clamp was placed.  aortotomies were made.  the vein was 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.  the patient was fully warmed and ventilation was commenced.  the patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  the patient was decannulated in 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 was closed with figure-of-eight of #1 vicryl, the sternal fascia closed with running #1 vicryl, the subcu closed with running 2-0 dexon, skin with running 4-0 dexon subcuticular stitch.  the patient tolerated the procedure well."
+"reason for visit:  syncope. history:  the patient is a 75-year-old lady who had a syncopal episode last night.  she went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  she did not have any residual deficit.  she had a headache at that time.  she denies chest pains or palpitations. past medical history:  arthritis, first episode of high blood pressure today.  she had a normal stress test two years ago. medications:  her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70. social history:  she does not smoke and she does not drink.  she lives with her daughter. physical examination:general:  lady in no distress.vital signs:  blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  afebrile.heent:  head is normal.neck:  supple.lungs:  clear to auscultation and percussion.heart:  no s3, no s4, and no murmurs.abdomen:  soft.extremities:  lower extremities, no edema. diagnostic data:  her ekg shows sinus rhythm with nondiagnostic q-waves in the inferior leads. assessment:  syncope. plan:  she had a ct scan of the brain that was negative today.  the blood pressure is high.  we will start maxzide.  we will do an outpatient holter and carotid doppler study.  she has had an echocardiogram along with the stress test before and it was normal.  we will do an outpatient followup."
+"reason for referral:  chest pain, possible syncopal spells. she is a very pleasant 31-year-old mother of two children with add. she was doing okay until january of 2009 when she had a partial hysterectomy.  since then she just says &quot;things have changed&quot;.  she just does not want to go out anymore and just does not feel the same.  also, at the same time, she is having a lot of household stressors with both of her children having add and odd and she feels she does not get enough support from her husband.  her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems. in this setting, she has been having multiple cardiovascular complaints including chest pains, which feel &quot;like cramps&quot; and sometimes like a dull ache, which will last all day long.  she is also tender in the left breast area and gets numbness in her left hand.  she has also had three spells of &quot;falling&quot;, she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes.  twice it happened, when getting up quickly at night and another time in the grocery store.  she suffered no trauma.  she has no remote history of syncope.  her weight has not changed in the past year. medications:  naprosyn, which she takes up to six a day. allergies:  sulfa. social history:  she does not smoke or drink.  she is married with two children. review of systems:  otherwise unremarkable. pex:  bp:  130/70 without orthostatic changes.  pr:  72.  wt:  206 pounds.  she is a healthy young woman.  no jvd.  no carotid bruit.  no thyromegaly.  cardiac:  regular rate and rhythm.  there is no significant murmur, gallop, or rub.  chest:  mildly tender in the upper pectoral areas bilaterally (breast exam was not performed).  lungs:  clear.  abdomen:  soft.  moderately overweight.  extremities:  no edema and good distal pulses. ekg:  normal sinus rhythm, normal ekg. echocardiogram (for syncope):  essentially normal study. impression:1.  syncopal spells &#8211; these do sound, in fact, to be syncopal.  i suspect it is simple orthostasis/vasovagal, as her ekg and echocardiogram looks good.  i have asked her to drink plenty of fluids and to not to get up suddenly at night.  i think this should take care of the problem.  i would not recommend further workup unless these spells continue, at which time i would recommend a tilt-table study.2.  chest pains &#8211; atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors.  the naprosyn is not helping that much, i gave her a prescription for flexeril and instructed her in its use (not to drive after taking it). recommendations:1.  reassurance that her cardiac checkup looks excellent, which it does.2.  drink plenty of fluids and arise slowly from bed.3.  flexeril 10 mg q 6 p.r.n.4.  i have asked her to return should the syncopal spells continue."
+"preoperative diagnosis:  acute appendicitis. postoperative diagnosis:  acute appendicitis. procedure:  laparoscopic appendectomy. anesthesia:  general endotracheal. indications:  patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain.  history as well as signs and symptoms are consistent with acute appendicitis as was his cat scan.  i evaluated the patient in the emergency room and recommended that he undergo the above-named procedure.  the procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery. findings:  patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration. technique:  the patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with betadine solution and draped in sterile fashion.  an infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an allis clamp and two stay sutures of 2-0 vicryl were placed on either side of the midline.  the fascia was tented and incised and the peritoneum entered by blunt finger dissection.  a hasson cannula was placed and a pneumoperitoneum to 15 mmhg pressure was obtained.  patient was placed in the trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed.  the appendix was easily visualized, grasped with a babcock&#8217;s.  a window was created in the mesoappendix between the appendix and the cecum and the endo gia was introduced and the appendix was amputated from the base of the cecum.  the mesoappendix was divided using the endo gia with vascular staples.  the appendix was placed within an endo bag and delivered from the abdominal cavity.  the intra-abdominal cavity was irrigated.  hemostasis was assured within the mesentery and at the base of the cecum.  all ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution.  the infraumbilical defect was closed with a figure-of-eight 0 vicryl suture.  the remaining wounds were irrigated and then everything was closed subcuticular with 4-0 vicryl suture and steri-strips.  patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition."
+"subjective:  the patient returns to the pulmonary medicine clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  she was last seen in the pulmonary medicine clinic in january 2004.  since that time, her respiratory status has been quite good.  she has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  she denies any problems with cough or sputum production.  no fevers or chills.  recently, she has had a bit more problems with fatigue.  for the most part, she has had no pulmonary limitations to her activity. current medications:  synthroid 0.112 mg daily; prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; plaquenil 200 mg b.i.d.; imuran 100 mg daily; advair one puff b.i.d.; premarin 0.3 mg daily; lipitor 10 mg monday through friday; actonel 35 mg weekly; and aspirin 81 mg daily.  she is also on calcium, vitamin d, vitamin e, vitamin c and a multivitamin. allergies:  penicillin and also intolerance to shellfish. review of systems:  noncontributory except as outlined above. examination:general:  the patient was in no acute distress.vital signs:  blood pressure 122/60, pulse 72 and respiratory rate 16.heent:  nasal mucosa was mild-to-moderately erythematous and edematous.  oropharynx was clear.neck:  supple without palpable lymphadenopathy.chest:  chest demonstrates decreased breath sounds, but clear.cardiovascular:  regular rate and rhythm.abdomen:  soft and nontender.extremities:  without edema.  no skin lesions.o2 saturation was checked at rest.  on room air it was 96% and on ambulation it varied between 94% and 96%.  chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  she has not had the previous chest x-ray with which to compare; however, i did compare the markings was less prominent when compared with previous ct scan. assessment:1.  lupus with mild pneumonitis.2.  respiratory status is stable.3.  increasing back and joint pain, possibly related to patient"
+"indications for procedure: a 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. the chest pain occurred early tuesday morning. she was treated with plavix, lovenox, etc., and transferred for coronary angiography and possible pci. the plan was discussed with the patient and all questions answered. procedure note: following sterile prep and drape, the right groin and instillation of 1% xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. a 6-french sheath inserted. selective left and right coronary injections performed using judkins coronary catheters with a 6-french pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. the left pullback pressure. the catheters withdrawn. sheath injection. hemostasis obtained with a 6-french angio-seal device. she tolerated the procedure well. left ventricular end-diastolic pressure equals 25 mmhg post a wave. no aortic valve or systolic gradient on pullback. angiographic findings:i. left coronary artery: the left main coronary artery isnormal. the left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. normal diagonal branches. normal septal perforator branches. the left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.ii. right coronary artery: the proximal right coronary artery has a focal calcification. there is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. the right coronary artery is a dominant system which gives off normal posteriordescending and posterior lateral branches. timi 3 flow is present.iii. left ventriculogram: the left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered). discussion: recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post a wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery. plan: medical treatment is contemplated, including ace inhibitor, a beta blocker, aspirin, plavix, nitrates. an echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction."
+reason for examination:  cardiac arrhythmia. interpretation:  no significant pericardial effusion was identified. the aortic root dimensions are within normal limits.  the four cardiac chambers dimensions are within normal limits.  no discrete regional wall motion abnormalities are identified.  the left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  the left ventricular wall thickness is within normal limits. the aortic valve is trileaflet with adequate excursion of the leaflets.  the mitral valve and tricuspid valve motion is unremarkable.  the pulmonic valve is not well visualized. color flow and conventional doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an rv systolic pressure calculated to be 28 mmhg.  doppler interrogation of the mitral in-flow pattern is within normal limits for age. impression:1.  preserved left ventricular systolic function.2.  mild mitral regurgitation.3.  mild tricuspid regurgitation.
+"cc: headache. hx: this 37y/o lhm was seen one month prior to this presentation for ha, nausea and vomiting. gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. these symptoms had been recurrent since onset. at presentation he complained of mild blurred vision (ou), difficulty concentrating and ha which worsened upon sitting up. the headaches were especially noticeable in the early morning. he described them as non-throbbing headaches. they begin in the bifrontal region and radiate posteriorly. they occurred up to 6 times/day. the ha improved with lying down or dropping the head down between the knees towards the floor. the headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. he denied any scotomata or positive visual phenomena. he denies any weakness, numbness, tingling, dysarthria or diplopia. his weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. his appetite has been especially poor in the past month. meds:sulfasalazine qid. tylenol 650mg q4hours. pmh: 1)ulcerative colitis dx 1989. 2)htn 3) occasional has since the early 1980s which are different in character and much less severe than his current has. they were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking. fhx: mgf with h/o stroke. mother and father were healthy. no h/o of migraine in family. shx: single. works as a newpaper printing press worker. denies tobacco, etoh or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit. exam: bp159/92 hr 48 (sitting): bp126/70 hr48 (supine). rr14 36.2c ms: a&#038;o to person, place and time. speech clear. appears uncomfortable but acts appropriately and cooperatively. no difficulty with short and long term memory. cn: grad 2-3 papilledema os; grade 1 papilledema (@2 o&#8217;clock) od. pupils 4/4 decreasing to 2/2 on exposure to light. bilateral horizontal sustained nystagmus on right and leftward gaze. bilateral vertical sustained nystagmus on up and downward gaze. face symmetric with full movement and pp sensation. tongue midline with full rom. gag and scm were intact bilaterally. motor: full strength throughout with normal muscle bulk and tone. sensory: unremarkable. coord: mild dysynergia on fnf movements in bue. hns and ram were unremarkable. station: unsteady with and without eyes open on romberg test. no drift in any particular direction. gait: wide based, ataxic and to some degree magnetic and apraxic. gen exam: unremarkable. course: urinalysis revealed 1-2rbc, 2-3wbc and bacteria were noted. repeat urinalysis was negative the next day. pt, ptt, cxr and gs were normal. cbc revealed 10.4wbc with 7.1granulocytes. hct, 10/18/95, revealed hydrocephalus. mri, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. there was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of magendie. these changes were felt suggestive of bacterial or granulomatous meningitis. the patient underwent ventriculostomy on 10/19/94. csf taken on 10/19/94 via v-p shunt insertion revealed: 22 wbc (21 lymphocytes, 1 monocyte), 380 rbc, glucose 58, protein 29, gs negative, cultures (bacterial, fungal, afb) negative, cryptococcal antigen and india ink were negative. numerous csf samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional csf protein of up to 99mg/dl. serum and csf toxoplasma titers and ace levels were negative on multiple occasions. vdrl and hiv testing was unremarkable. 10/27/94 and 10/31/94 csf cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. the patient was treated with amphotericin and showed some improvement. however, scarring had probably occurred by then and the v-p shunt was left in place."
+"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."
+"cc: left hand numbness on presentation; then developed lethargy later that day. hx: on the day of presentation, this 72 y/o rhm suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. four hours later he experienced sudden left hand numbness lasting two hours. there were no other associated symptoms except for the generalized weakness and lightheadedness. he denied vertigo. he had been experiencing falling spells without associated loc up to several times a month for the past year. meds: procardia sr, lasix, ecotrin, kcl, digoxin, colace, coumadin. pmh: 1)8/92 evaluation for presyncope (echocardiogram showed: av fibrosis/calcification, av stenosis/insufficiency, mv stenosis with annular calcification and regurgitation, moderate tr, decreased lv systolic function, severe lae. mri brain: focal areas of increased t2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. ivg (muga scan)revealed: global hypokinesis of the lv and biventricular dysfunction, rv ejection fx 45% and lv ejection fx 39%. he was subsequently placed on coumadin severe valvular heart disease), 2)htn, 3)rheumatic fever and heart disease, 4)copd, 5)etoh abuse, 6)colonic polyps, 7)cad, 8)chf, 9)appendectomy, 10)junctional tachycardia. fhx: stroke, bone cancer, dementia. shx: 2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. denies illicit drug use. exam: 36.8c, 90bpm, bp138/56. ms: alert and oriented to person, place, but not date. hypophonic and dysarthric speech. 2/3 recall. followed commands. cn: left homonymous hemianopia and left cn7 nerve palsy (old). motor: full strength throughout. sensory: unremarkable. coordination: dysmetric fnf and hks movements (left worse than right). station: rue pronator drift and romberg sign present. gait: shuffling and bradykinetic. reflexes: 1+/1+ to 2+/2+ and symmetric throughout. plantar responses were flexor bilaterally. heent: neck supple and no carotid bruits. cv: rrr with 3/6 sem and diastolic murmurs throughout the precordium. lungs: bibasilar crackles. labs: pt 19 (elevated) and ptt 46 (elevated). course: coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. the initial hct revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. he was scheduled to undergo an mri brain scan the same day, and shortly before the procedure became lethargic. by the time the scan was complete he was stuporous. mri scan then revealed a hypointense area of t1 signal in the right temporal lobe with a small foci of hyperintensity within it. the hyperintense area seen on t1 weighted images appeared hypointense on t2 weighted images. there was edema surrounding the lesion the findings were consistent with a hematoma. a ct scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. the patient subsequently died."
+"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&#8217;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.7.  nutrition.  his albumin is 3.2 and this is fairly close to his baseline over the past several months.8.  hiv.  his most recent cd4 count is 350.  he has been very compliant, it seems, with his antiretroviral therapy.  he has followup with dr. y.9.  transplant candidacy.  i have informed the patient that he may indeed be a candidate for transplant, although he is likely to need dialysis before he could be transplanted.  i have instructed him to try to stop smoking.  this is for making him a better candidate.  i have also encouraged him to continue to be compliant with his antiretroviral therapies as this would be a requirement for transplant. disposition:  the patient is to return to clinic in one month&#8217;s time."
+"chief complaint:  intractable epilepsy, here for video eeg. history of present illness:  the patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  ultimately, imaging study shows an mri with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  he has had severe global developmental delay, and is nonverbal.  he can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  he has noted if any purposeful use of the hands.  he has abnormal movements constantly, which are more choreiform and dystonic.  he has spastic quadriparesis, which is variable at times.  the patient is unable to sit or stand, and receives all his nutrition via g-tube. the patient began having seizures in infancy presenting as infantile spasms.  i began seeing him at 20 months of age.  at that point, he had undergone workup in seattle, washington and then was seeing dr. x, child neurologist in mexico, who started vigabatrin for infantile spasms.  the patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  he initially was on phenobarbital, which failed to give him benefit.  he continued on phenobarbital; however, for a long period time thereafter.  the patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, topamax, and zonegran at least briefly.  upon starting lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  it was more recently that he began having new seizure events that have not responded to higher doses of lamictal up to 15 mg/kg/day.  these events manifest as tonic spells with eye deviation and posturing.  mother reports flexion of the upper extremities, extension with lower extremities.  during that time, he is not able to cry or say any sounds.  these events last from seconds to minutes, and occur at least multiple times per week.  there are times where he has none for a few days and other times where he has multiple days in a row with events.  he has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  he may vomit after these episodes, then seems to calm down.  it is unclear whether this is a seizure or whether the patient is still responsive. medications:  the patient&#8217;s medications include lamictal for a total of 200 mg twice a day.  it is a 150 mg tablet and 25 mg tablets.  he is on zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  he has other medications including the xopenex and atrovent. review of systems:  at this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  no respiratory or cardiovascular complaints.  he has no change in his skills at this point. family history:  noncontributory. physical examination:general:  the patient is a slender male who is microcephalic.  he has eeg electrodes in place and is on the video eeg at that time.heent:  his oropharynx shows no lesions.neck:  supple without adenopathy.chest:  clear to auscultation.cardiovascular:  regular rate and rhythm.  no murmurs.abdomen:  benign with g-tube in place.extremities:  reveal no clubbing, cyanosis, or edema.neurological:  the patient is alert and has bilateral esotropia.  he is able to fix and follow objects briefly.  he is unable to reach for objects.  he exhibits constant choreiform movements when excited.  these are more prominent in the upper extremities and lower extremities.  he has some dystonic posture with flexion of the wrist and fingers bilaterally.  he also has plantar flexion at the ankles bilaterally.  his cranial nerves reveal that his pupils are equal, round, and reactive to light.  extraocular movements are intact other than bilateral esotropia.  his face moves symmetrically.  palate elevates in midline.  hearing appears intact bilaterally. motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  he has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  his sensation is intact to light touch bilaterally.  deep tendon reflexes are 2 to 3+ bilaterally. impression/plan:  this is a 9-year-old male with congenital brain malformation and intractable epilepsy.  he has microcephaly as well as dystonic cerebral palsy.  he had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  he is admitted for video eeg to hopefully capture both of these episodes and further clarify the seizure type or types.  he will remain hospitalized for probably at least 48 hours to 72 hours.  he could be discharged sooner if multiple events are captured.  his medications, we will continue his current dose of zonegran and lamictal for now.  both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge."
+"identifying data:  the patient is a 41-year-old african-american male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability. chief compliant:  &quot;i&#8217;m here because i&#8217;m different.&quot; the patient exhibits poor insight into illness and need for treatment. history of present illness:  the patient has a history of bipolar affective disorder and poor outpatient compliance.  according to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile.  the patient had expressed grandiose delusions that he is martin luther king, and was found recently at a local church agitated throwing a pew and a lectern and required tasering by police.  on admission interview, the patient remains euphoric with poor insight. past psychiatric history:  history of bipolar affective disorder.  the patient has been treated with depakote and seroquel, but has had no recent treatment or followup.  dates of previous hospitalizations are not known. past medical history:  none known. current medications:  none. family social history:  unemployed.  the patient resides independently.  the patient denies recent substance abuse, although tox screen was positive for benzodiazepines. legal history:  need to increase database. family psychiatric history:  need to increase database. mental status examination:  attitude:  suspicious, but cooperative.appearance:  shows appropriate hygiene and grooming.psychomotor behavior:  within normal limits.  no agitation or retardation.  no eps or tds noted.affect:  labile.mood:  euphoric.speech:  pressured.thoughts:  disorganized.thought content:  remarkable for grandiose delusions as noted.  the patient denies auditory hallucinations.psychosis:  grandiose delusions as noted above.suicidal/homicidal ideation:  the patient denies on admission.cognitive assessment:  grossly intact.  the patient is oriented x 3.judgment:  poor shown by noncompliance to the outpatient treatment.assets:  include stable physical status.limitations:  include recurrent psychosis. formulation:  the patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment. initial impression:axis i:  bad, manic with psychosis.axis ii:  none.axis iii:  none known.axis iv:  severe.axis v:  10. estimated length of stay:  12 days. plan:  the patient will be restarted on depakote for mood lability and seroquel for psychosis and his response will be monitored closely.  the patient will be evaluated for more structural outpatient followup following stabilization."
+"identification of patient:  the patient is a 34-year-old caucasian female. chief complaint:  depression. history of present illness:  the patient&#8217;s depression began in her teenage years.  sleep has been poor, for multiple reasons.  she has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  the patient tends to feel irritable, and has crying spells.  she sometimes has problems with motivation.  she has problems with memory, and energy level is poor. appetite has been poor, but without weight change.  because of her frequent awakening, her cpap machine monitor has indicated she is not using it enough, and medicaid is threatening to refuse to pay for the machine.  she does not have suicidal thoughts.   the patient also has what she describes as going into a &quot;panic mode.&quot;  during these times, she feels as if her whole body is going to explode.  she has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  these spells may last a couple of hours, but once lasted for about two day.  she does not get chest pain.  these attacks tend to be precipitated by bills that cannot be paid, or being on a &quot;time crunch.&quot;  psychiatric history:  the patient&#8217;s nurse practitioner had started her on cymbalta, up to 60 mg per day. this was helpful, but then another physician switched her to wellbutrin in the hope that this would help her quit smoking.  although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  she has used wellbutrin up to 200 mg b.i.d. and cymbalta up to 60 mg per day, at different times.  at age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  she has never been hospitalized for psychiatric purposes.  she did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  she has not previously spoken with a psychiatrist, but has been seeing a therapist, stephanie kitchen, at this facility. substance abuse history:caffeine:  the patient has two or three drinks per day of tea or diet pepsi.tobacco:  she smokes about one pack of cigarettes per week since being on wellbutrin, and prior to that time had been smoking one-half pack per day.  she is still committed to quitting.alcohol: denied.illicit drugs:  denied.  in her earlier years, someone once put some unknown drug in her milk, and she &quot;came to&quot; when she was dancing on the table in front of the school nurse. medical history/review of systems:constitutional:  see history of present illness. no recent fever or sweats.   neurological:  no history of seizures.  she does have migraine headaches, and has been diagnosed with restless leg syndrome.  when she was small, she twice fell on cinder blocks and struck her head, losing consciousness; she has a facial scar from one of those incidents.  when she was about 3 or 4 years of age, they were playing baseball with a cup being used as a ball, and her brother accidentally hit her in the forehead with a bat; she did not lose consciousness that time.  heent:  the patient states she needs glasses, but cannot afford them. cardiovascular:  hypertension.  pulmonary:  obstructive sleep apnea.  gastrointestinal:  recurrent epigastric pain, relieved by prevacid.  no history of liver disease.  endocrine and hematological:  the patient is hypothyroid, has diabetes mellitus, but no hematological disorder.  dermatological:  denied.  musculoskeletal:  chronic back pain.  the patient has had some nerve ablation, but feels the nerves have been growing back, as the pain has worsened.  she also has right knee pain.  genitourinary:  stress incontinence.  other:  obesity and hypercholesterolemia.  surgeries:  bilateral tubal ligation, and partial hysterectomy in 2003 for menorrhagia.  she has had several miscarriages. allergies:  penicillin and tetanus. current medications:prescription:  wellbutrin 200 mg b.i.d., but she has been given a prescription for cymbalta 30 mg per day, which she was instructed to start within the next few days.  she also takes ambien (ineffective), l-thyroxin, lisinopril, hydrochlorothiazide, metformin, zocor, an unknown medication for restless legs, ultram, lidoderm patch, and zanaflex. she also takes prevacid.over-the-counter:  multivitamins.herbal:  denied. developmental history:  the patient was born fullterm, vaginally, after a normal pregnancy.  she walked around the furniture at 9 months of age, but did not walk by herself until 14 months of age. abuse history/trauma/unusual childhood events:   the patient was molested by cousins and by her mother&#8217;s boyfriends.  her parents separated when she was 2 years of age, and divorced just before sixth birthday.  her mother often had parties, and the children were unsupervised.  she was raped at age 15 by a boyfriend.   family psychiatric history:  her son has adhd.  her daughter has depression. her mother has depression and possibly even bipolar disorder.  her mother has had substance abuse issues, primarily cannabis and alcohol, but other drugs as well.  her great grandmother on her father&#8217;s side has alzheimer&#8217;s disease. family medical history:  the patient&#8217;s mother was adopted, so she only recently learned about family medical history.  an aunt has hypothyroidism, and there is diabetes mellitus on both sides of the family.  there are also individuals with cerebral palsy, multiple sclerosis, an unknown type of cancer, hypertension, and obesity.   social history:  the patient was born in savannah, georgia.  she came to alaska in 2001 because her husband had lost his trucking job (the company filed bankruptcy) and they had become homeless in south carolina.  because her mother was residing in alaska, her husband sent her here, but shortly thereafter they were evicted from that home as well; the building was being sold.  she has a daughter, age 13, and twins (a boy and a girl), age 10.  she has been married for 14 years.  she is presently unemployed, but plans to go on a job interview today with alaska usa federal credit union.  she is of pentecostal faith, but only occasionally attends church.  they have had some major difficulties with their church of choice.  at one point, the youth pastor accused her husband of stealing his laptop computer and a credit card; although, it was later found that one of the young people in the church had been the culprit, and no one ever apologized to her husband.  later on, they were assisting the new youth pastor with a yard sale, and someone stole the proceeds from the sale, as well as some discount cards.  her husband was again accused, but it was later learned through tracing the discount cards who the thief was.  they feel that the people in the church have viewed them suspiciously, and have not apologized for the false accusations.   educational:  she quit high school twice, the second time being before the last semester of her senior year.  she later earned a ged, after being married. legal:  she has never been charged with any crime, but was once accused of carrying a knife that was too long by perhaps a quarter inch. mental status:  the patient is alert, pleasant, and cooperative.  she arrived on time.  grooming is fair to good.  intelligence is at least average.  she is oriented to time, place and person.  eye contact is good.  she is able to spell the word &quot;world&quot; in both forward and reverse directions accurately.  memory is good for immediate recall of three objects, but she recalls only two of the three after a couple of minutes.  she recalls presidents bush, clinton, bush, and reagan.  mood is depressed, and affect is consistent with mood.  speech is highly circumstantial and mildly tangential, but of normal rate and tone.  insight and judgment are good.  she denies auditory or visual hallucinations.  there is no overt sign of psychosis.  she denies suicidal or homicidal ideation.  she interprets the proverb, &quot;people who live in glass houses shouldn&#8217;t throw stones&quot; as meaning, &quot;don&#8217;t talk about people and you are doing the same thing.&quot; formulation:  the patient is a 34-year-old caucasian female with a long history of depression, with complex nonpsychiatric medical issues.   diagnoses:axis  i  296.33 major depression, recurrent, severe, without psychotic features. 300.21 rule out panic disorder without agoraphobia.axis  ii  301.9 personality disorder, not otherwise specified.axis iii  obesity, diabetes mellitus, stress incontinence, hypercholesterolemia, chronic back and leg pain, epigastric pain, hypothyroidism, hypertension, obstructive sleep apnea, restless leg syndrome, migraine headaches.axis iv  problems related to the primary support group, financial problems, other psychosocial and environmental problems.axis v    gaf:  48, current.  highest in past year:  55. strengths:  normal intelligence, high school equivalency diploma, desire to feel better.  prognosis:  guarded, due to the patient&#8217;s rather complex medical issues. with proper treatment, it will be possible to maximize her psychosocial functioning, in spite of her limitations.  without treatment, her functioning will most likely deteriorate rather substantially and seriously impact her life. plan:  we discussed in particular the risks and benefits of wellbutrin, cymbalta, and some potential medication interactions.  because the ambien is ineffective, it should be discontinued.  i have instructed her to decrease wellbutrin to 200 mg per day for the next week, then discontinue.  she should start cymbalta 30 mg per day immediately.   return to clinic two weeks, at which time we will consider further medication adjustment.  she is to call the clinic nurse in the interim if symptoms warrant."
+"reason for consult:  a patient with non-q-wave myocardial infarction. history of present illness:  the patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks.  the patient reports having worsening emesis and emesis a few times.  no definite chest pains.  the patient is breathing okay.  the patient denies orthopnea or pnd. past medical history:1.  diabetes mellitus.2.  hypertension.3.  renal failure, on dialysis. medications:  aspirin, coreg, doxazosin, insulin, metoclopramide, simvastatin, and starlix. allergies:  no known drug allergies. social history:  the patient denies tobacco, alcohol or drug use. family history:  negative for early atherosclerotic heart disease. review of systems:  general:  the patient denies fever or chills.  pulmonary:  the patient denies hemoptysis.  cardiovascular:  refer to hpi.  gi:  the patient denies hematemesis or melena.  the rest of systems review is negative. physical examination:vital signs:  pulse 71, blood pressure 120/70, and respiratory rate 18.general:  a well-nourished, well-developed male in no acute distress.heent:  normocephalic, atraumatic.  pupils seem to be equal, round, and reactive.  extraocular muscles are full, but the patient has left eye ptosis.neck:  supple without jvd or lymphadenopathy.lungs:  clear to auscultation bilaterally.cardiovascular:  pmi is displaced 0.5 cm lateral to the midclavicular line.  regular rate and rhythm, s1, s2.  no definite s3, 2/6 holosystolic murmur at the apex radiating to the axilla.abdomen:  positive bowel sounds, nondistended and nontender.  no hepatosplenomegaly.extremities:  trace pedal edema. ekg shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.  subsequent ekg in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with q-waves in v1, v2, and up to v3. laboratory exam:  wbc 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000.  pt 11.3, inr 1.1, and ptt 24.1.  sodium 126, potassium 4.3, chloride 86, co2 26, glucose 371, bun 80, and creatinine 8.4.  ck was 261, then 315, and then 529 with ck-mb of 8.06, then 8.69, and then 24.6.  troponin was 0.051, then 0.46, and then 19.8 this morning. impression:1.  paroxysmal atrial fibrillation.  the heart rate was slowed down with iv cardizem, the patient converted to sinus rhythm.  the patient is currently in sinus rhythm.2.  emesis.  the etiology is unclear.  the patient reports that the emesis is better.  the patient is just having some nausea.3.  non-q-wave myocardial infarction.  ekg shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.4.  diabetes mellitus.5.  renal failure.6.  hypertension.7.  hypercholesterolemia. plan:1.  we will start amiodarone to keep from going back into atrial fibrillation.2.  echocardiogram.3.  aspirin and iv heparin.4.  serial ck-mb and troponin.5.  cardiac catheterization, possible percutaneous coronary intervention.  the risks, benefits, and alternatives were explained to the patient through a translator.  the patient understands and wishes to proceed.6.  iv integrilin."
+"chief reason for consultation:  evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month. history of present illness:  this 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  this lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  patient does not get any chest pain or choking in the neck or pain in the back.  patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  her exercise tolerance is one to two blocks for shortness of breath and easy fatigability. medications:  patient does not take any specific medications. past history:  the patient underwent hysterectomy in 1986. family history:  the patient is married, has four children who are doing fine.  family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident. social history: the patient smokes one pack of cigarettes per day and takes drinks on social occasions.      allergies:  the patient is allergic to codeine. review of systems:  remarkable for heavy snoring, daytime sleepiness, and easy fatigability. physical examination:  general:  well-built, well-nourished black female in no acute distress. vital signs:  blood pressure is 120/80.  respirations 18 per minute.  heart rate 70 beats per minute.  patient weighs 226 pounds, height 68 inches.  bmi is 34.heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good.neck:  supple.  no cervical lymphadenopathy. carotid upstroke is good. no bruit heard over the carotid or subclavian arteries.  trachea in midline. thyroid not enlarged.  jvp flat at 45&deg;.chest:  chest is symmetrical on both sides, moves well with respirations.  vesicular breath sounds heard over the lung fields.  no wheezing, crepitation, or pleural friction rub heard.  cardiovascular system:  pmi felt in fifth left intercostal space within midclavicular line. first and second heart sounds are normal in character.  there is no murmur, gallop, or pericardial friction rub heard.abdomen:  soft.  there is no hepatosplenomegaly or ascites.  no bruit heard over the aorta or renal vessels.extremities:  no pedal edema or calf muscle tenderness.  proximal and distal arterial pulsations are well felt. ekg shows normal sinus rhythm, negative t waves in leads 1, avl, v4-v6. impression:   1.  abnormal ekg showing diffuse anterior wall ischemia.2.  discomfort left upper arm highly suggestive of angina pectoris.3.  obesity.4.  obstructive sleep apnea syndrome. plan:  1.  stress myoview spect, echocardiogram.2.  sleep apnea study.3.  routine blood tests.4.  patient will be seen again in my office in two weeks."
+"admitting diagnosis:  gastrointestinal bleed. history of present illness:  ms. xyz is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  she states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  she noticed it was very dark and smelly.  she said she felt okay.  she got up.  she proceeded to clean her house without any difficulty or problems and then at approximately 2 o&#8217;clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  she is able to get to her phone, called ems and when the ems arrived they found her with some blood and some very dark stools.  she states that she was perfectly fine up until monday when she had an incident where at the southern university where she works where there was an altercation between a dorm resistant and a young male, which ensued.  she came to place her call, etc.  she said she noticed her stomach was hurting after that, continued to hurt and she took the day off on tuesday and this happened yesterday.  she denies any nausea except for when she got weak.  she denies any vomiting or any other symptoms. allergies:  she has no known drug allergies. current medications:1.  lipitor, dose unknown.2.  paxil, dose unknown.3.  lasix, dose unknown.4.  toprol, dose unknown.5.  diphenhydramine p.r.n.6.  ibuprofen p.r.n.7.  daypro p.r.n. past medical history:1.  non-insulin diabetes mellitus.2.  history of congestive heart failure.3.  history of hypertension.4.  depression.5.  arthritis.  she states she has not needed any medications and not taken ibuprofen or daypro recently.6.  hyperlipidemia.7.  peptic ulcer disease diagnosed in 2005. past surgical history:  c-section and tonsillectomy. family history:  her mother had high blood pressure and coronary artery disease. social history:  she is a nonsmoker.  she occasionally has a drink every few weeks.  she is divorced.  she has 2 sons.  she is houseparent at southern university. review of systems:  negative for the last 24 to 48 hours as mentioned in her hpi. preventive care:  she had an egd done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon. physical examination:vital signs:  currently was stable.  she is afebrile.general:  she is alert, pleasant in no acute distress.  she does complain of some dizziness when she stands up.heent:  pupils equal, round and reactive to light.  extraocular muscles intact.  sclerae clear.  oropharynx is clear.neck:  supple.  full range of motion.cardiovascular:  she is slightly tachycardic but otherwise normal.lungs:  clear bilaterally.abdomen:  soft, nontender, and nondistended.  she has no hepatomegaly.extremities:  no clubbing, cyanosis, only trace edema. laboratory data upon admission:  her initial chem panel was within normal limits.  her pt and ptt were normal.  her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  she is currently administered transfusion.  platelet count was 125.  her chem panel actually showed an elevated bun of 16, creatinine of 1.7.  pt and ptt were normal.  cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood. impression and plan:1.  gastrointestinal bleed.    appears to be a lower gastrointestinal bleed; however, given her history of peptic ulcer disease cannot rule out an upper bleed.  we will plan to keep her npo, put on iv ppis.  we will transfuse as needed and schedule for an esophagogastroduodenoscopy and colonoscopy in the morning.2.  diabetes mellitus.  we will continue to watch her diet and sliding scale as needed.  she currently is npo, put on d5 maintenance fluid.3.  history of congestive heart failure and hypertension.  we will have to watch closely.4.  other medical problems currently stable."
+"reason for consult:  dementia. history of present illness:  the patient is a 33-year-old black female, referred to the hospital by a neurologist in tyler, texas for disorientation and illusions.  symptoms started in june of 2006, when the patient complained of vision problems and disorientation.  the patient was seen wearing clothes inside out along with other unusual behaviors.  in august or september of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense.  the patient sought treatment from an ophthalmologist.  we did not find any abnormality in the behavior center in tyler, texas.  the behavior center referred the patient to dr. abc, a neurologist in tyler, who then referred the patient to this hospital. according to the mother, the patient has had no past major medical or psychiatric illnesses.  the patient was functioning normally before june 2006, working as accounting tech after having completed 2 years of college.  she reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety.  currently, the patient lives with mother and requires her assistance to perform adls and the patient has become ataxic since november 2006.  sleeping patterns and the amount is unknown.  appetite is okay. past psychiatric history:  the patient was diagnosed with severe depression in november 2006 at the behavior center in tyler, texas, where she was given effexor.  she stopped taking it soon after, since they worsened her eye vision and balance. past medical history:  in 2001 diagnosed with meniere disease, was treated such that she could function normally in everyday activities including work.  no current medications.  denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury. family medical history:  father&#8217;s grandmother was diagnosed with alzheimer disease in her 70s with symptoms similar to the patient described by the patient&#8217;s mother.  both, the mother&#8217;s father and father&#8217;s mother had &quot;nervous breakdowns&quot; but at unknown dates. social history:  the patient lives with a mother, who takes care of the patient&#8217;s adls.  the patient completed school, up to two years in college and worked as accounting tech for eight years.  denies use of alcohol, tobacco, or illicit drugs. mental status examination:  the patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel.  decreased motor activity, but did blink her eyes often, but arrhythmically.  poor eye contact.  speech illogic.  concentration was not able to be assessed.  mood is unknown.  flat and constricted affect.  thought content, thought process and perception could not be assessed.  sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient. mini-mental status exam:  unable to be performed. axis i:  rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.axis ii:  deferred.axis iii:  deferred.axis iv:  deferred.axis v:  1. assessment:  the patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history.  there is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate.  the patient presented with headaches, vision forms, and disorientation in june 2006.  she currently presents with ataxia, vision loss, and illusions. plan:  wait for result of neurological tests.  thank you very much for the consultation."
+"<strong>preoperative diagnosis: </strong>hypoxia and increasing pulmonary secretions. <strong> postoperative diagnosis: </strong>hypoxia and increasing pulmonary secretions. <strong>operation: </strong>bronchoscopy. <strong>anesthesia: </strong>moderate bedside sedation. <strong>complications:</strong> none. <strong>findings:</strong> abundant amount of clear thick secretions throughout the main airways. <strong>indications:</strong> the patient is a 43-year-old gentleman who has been in the icu for several days following resection of small bowel for sequelae of smv occlusion. this morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his et tube. the patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be. <strong>operation:</strong> the patient was given additional fentanyl, versed as well as paralytics for the procedure. small bronchoscope was inserted through the et tube and to the trachea to the level of carina. there was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. extensive secretions extended down into the secondary airways. this was lavaged with saline and suctioned dry. there is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. the bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. the bronchoscope was removed, and the patient was increased to peep of 10 on the ventilator. please note that prior to starting bronchoscopy, he was pre oxygenated with 100% o2. the patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture."
+"<strong>identifying data:</strong> the patient is a 36-year-old caucasian male. <strong>chief complaint:</strong> the patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted. <strong>history of present illness:</strong> the patient has been receiving services at this facility previously, under the care of abc, m.d., and later xyz, m.d. historically, he has found it very easy to be distracted in the &#8220;cubicle&#8221; office setting where he sometimes works. he first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. in the past, probably in high school, the patient recalled being more figidity than now. he tensed to feel anxious. sleep has been highly variable. he will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. appetite has been good. he has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking adderall. he tends to feel depressed. his energy level is &#8220;better now,&#8221; but this was very problematic in the past. he has problems with motivation. in the past, he had passing thoughts of suicide, but this is no longer a problem. <strong>psychiatric history:</strong> the patient has never been hospitalized for psychiatric purposes. his only treatment has been at this facility. he tried adderall for a time, and it helped, but he became hypertensive. lunesta is effective for his insomnia issues. effexor has helped to some degree. he has been prescribed provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. he sometimes takes the other half of the tablet in the afternoon. <strong>substance abuse history:</strong> caffeine: two or three cups of coffee per day, and soda at lunch time. tobacco: denied. alcohol: one glass of wine per week. the cage screening questions are answered in the negative. illicit drugs: none at present. in high school, he tried marijuana a couple of times, and cocaine once. we discussed some of the major risk of these substances. <strong>medical history and review of symptoms:</strong> constitutional: see history of present illness. no recent fever or sweats. neurological: no history of seizures or migraine headaches. the patient did have a wrestling injury that resulted in a hole in one retina, but he had no loss of consciousness with that injury. heent: as mentioned above, &#8220;hole&#8221; in one retina. cardiovascular: the patient has been hypertensive in the past with adderall, and recently he has had some episodes where his blood pressure was noted to be high, which may be related to his back pain. pulmonary: denied. gastrointestinal: gerd. the patient has ongoing nausea, which is thought possibly to be related to adhesions. he has no history of liver disease or peptic ulcer disease. endocrine and hematological: denied. dermatological: eczema as a child. musculoskeletal: chronic back pain from the herniated disc. he was involved in a motor vehicle accident, a head-on bus crash in the distant past. he is presently awaiting evaluation for possible surgery. genitourinary: denied. other: denied. <strong>surgeries:</strong> nissen fundoplication for gerd. removal of necrotic tissue from his left flank, following an accidental gunshot wound at age 18; the patient dropped a 44-caliber ruger, which discharged. <strong>allergies:</strong> no known drug allergies. <strong>current medications:</strong> prescription: provigil 100 mg q.a.m. and sometimes 100 mg in the afternoon. the full 200 mg dose caused the patient to &#8220;feel wired.&#8221; effexor-xr 75 mg q.a.m., lunesta 2 mg q.h.s., generic vicodin p.r.n back pain. over-the-counter: denied. herbal: denied. <strong>birth and developmental history:</strong> the patient believes he was probably born fullterm, but is not sure, after a normal pregnancy. he had a nuchal cord. he weighted about 6-1/2 pounds. he believes he reached the developmental milestones at the usual ages. <strong>abuse history/trauma/unusual childhood events:</strong> the patient does not really feel he was abused as a child, but there were some significant problems when his father returned from his second army tour in vietnam. he had not met his father until 2 years of age. he states that his father verbally abused his mother. he can recall that at about age 3, his father left him on the road, in order to shut him up. his mother eventually put down her foot, and told his father to quit drinking or they would separate, and his father chose to give up alcohol. this resulted in much better family relations. <strong>family psychiatric history:</strong> the patient&#8217;s father has suffered from posttraumatic stress disorder, as well as alcoholism. the patient&#8217;s mother has had similar symptoms, possibly adhd, and there is depression on the mother side of the family. there apparently are a number of family members with alcohol issues. <strong>family medical history:</strong> the patient&#8217;s grandfather had a myocardial infarction at age 40, and then died of another mi in his 50&#8242;s. the patient&#8217;s mother had breast cancer. his father had a stroke and hypertension. his maternal grandmother was obese and had diabetes mellitus. the maternal grandmother died of colon cancer. <strong>social history:</strong> the patient was born in grand junction, colorado. he came to alaska in 1977; his father left his last term of service in the army in germany at that time, and they came to alaska to help a grandparent build a cabin; they ended up staying. the patient has been married for 9 years. he has two daughters, ages 8 and 6. <strong>spiritual beliefs:</strong> he denies any spiritual beliefs. <strong>education:</strong> he has a bachelor of science degree from the university of oregon. <strong>employment:</strong> he is employed at fort richardson, through colorado state university, as a biologist. <strong>legal:</strong> he denies any legal problems. <strong>mental status examination:</strong> the patient arrived on time. he is alert, pleasant, and cooperative. he is well groomed and maintains good eye contact. intelligence is above average. insight and judgment are good. he is oriented to time, place, and person. memory is good for immediate and recent recall of three objects. he recalls presidents bush, clinton, and bush. he is able to spell the word &#8220;world&#8221; in both forward and reverse directions accurately, but with a bit of difficulty in reverse. speech is goal-directed, coherent, and of normal rate and tone. mood is &#8220;good,&#8221; but affect is anxious. the patient becomes more anxious with some of the questioning during the mental status examination, particularly proverb interpretation. he denies auditory or visual hallucinations. he denies suicidal or homicidal ideation. he states that the proverb, &#8220;people who live in glass houses shouldn&#8217;t throw stones&#8221; is &#8220;speaking about not being hypocritical.&#8221; <strong>formulation:</strong> the patient is a 36-year-old caucasian male with a long history of depression and attention deficits. hyperactivity criteria are essentially absent. although medications have been somewhat efficacious, he has residual symptoms that are quite troublesome. <strong>diagnoses:</strong> <strong>axis i</strong> 296.32 major depression, recurrent, moderate. 314.00 attention-deficit hyperactivity disorder, inattentive type. <strong>axis ii</strong> v71.09 no diagnosis. <strong>axis iii</strong> history of gastroesophageal reflux disease, status post nissen fundoplication, variable hypertension of uncertain etiology, retinal damage from the wrestling injury, chronic back pain. <strong>axis iv</strong> occupational problems, other psychosocial and environmental problems. <strong>axis v</strong> current gaf: 54. highest in the past year: 54. <strong>strengths:</strong> above average intelligence, college education, stable employment. <strong>prognosis:</strong> good, if the patient follows through with appropriate treatment. without proper treatment, the patient will likely have further substantial deterioration of psychosocial functioning. <strong>plan/recommendation:</strong> we have checked the patient&#8217;s blood pressure today, and it is 140/94. however, he is experiencing a considerable amount of back pain at this time, which likely contributes to this. we discussed some of the treatment options, and the patient will return within the next few days to have his blood pressure checked again. if it remains high, he has been instructed to see his primary care provider for further treatment. if blood pressure resolves with better pain control, we will strongly consider increasing effexor-xr. we discussed in some detail the risks and benefits of lunesta, provigil, and effexor-xr, and the patient signed a formal consent form. return to clinic in three weeks. <embed id=siber_embed1 style=left: 0px; 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+"<strong>reason for consultation:</strong> syncope. <strong>history of present illness: </strong>the patient is a 78-year-old lady followed by dr. x in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. according to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out. as soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion. according to the daughter, she has had episodes of weakness, but no syncope. she has blood pressure medications and has had some postural hypotensions, which has been managed by dr. x. she also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode. at that time, she was admitted at hospital, had a v/q scan, which was positive for pe. initial v/q scan done at hospital was negative. she was anticoagulated with coumadin resulting in severe gi bleed. anticoagulation was stopped and an ivc filter was placed at that time. she has a history of malignant hypertension and has had a renal stent placed in february 2007. she also has peripheral vascular disease with stent placements. there is a history of spinal canal stenosis and iron deficiency anemia, currently on procrit injections every two weeks done by dr. y. the patient denies any chest pain or any worsening of any shortness of breath. there are no acute ekg changes or cardiac enzyme elevations. she has had no stress test done following a bypass surgery. <strong>past medical history</strong> 1. coronary artery disease, status post coronary artery bypass grafting. 2. history of mitral regurgitation, unable to repair the valve. 3. history of paroxysmal atrial fibrillation, on amiodarone. 4. gastroesophageal reflux disease. 5. hypertension. 6. hyperlipidemia. 7. history of abdominal aortic aneurysm. 8. carotid artery disease, mild-to-moderate on recent carotid ultrasound. 9. peripheral vascular disease. 10. hypothyroidism. 11. pulmonary embolism. <strong>past surgical history</strong> 1. coronary artery bypass grafting. 2. hysterectomy. 3. ivc filter. 4. tonsillectomy and adenoidectomy. 5. cosmetic surgery to breast and abdomen. <strong>home medications</strong> 1. aspirin 81 mg once a day. 2. klor-con 10 meq once a day. 3. lasix 40 mg once a day. 4. levothyroxine 125 mcg once a day. 5. lisinopril 20 mg once a day. 6. pacerone 200 mg once a day. 7. protonix 40 mg once a day. 8. toprol 50 mg once a day. 9. vitamin b once a day. 10. zetia 10 mg once a day. 11. zyrtec 10 mg once a day. <strong>allergies:</strong> codeine, erythromycin, sulfa, vicodin, and zocor. <strong>review of systems</strong> constitutional: the patient denies any fevers, chills, recent weight gain or weight loss. she has had abdominal symptoms with diarrhea. eyes: decreased visual acuity. ent: sinus drainage. cardiovascular: as described above. denies any chest pains. respiratory: he has chronic shortness of breath. no cough or sputum production. gi: history of reflux symptoms. gu: no history of dysuria or hematuria. endocrine: no history of diabetes. musculoskeletal: denies arthritis, but has leg pain. skin: no history of rash. psychiatric: no history of anxiety or depression. cns: history of strokes and mri, but no focal deficits. review of other systems is essentially unremarkable. <strong>family history: </strong>father died at the age of 75 following a motor vehicle accident. mother died at the age of 32, no known heart problems. one brother died of cancer, one sister with cancer. <strong>social history: </strong>history of tobacco use, smoked for 20 years, and quit 30 years ago. alcohol one to two drinks monthly. <strong>physical examination</strong> general: elderly lady in no acute distress. vital signs: heart rate 50 to 60s, weight is 180 pounds, temperature 98.6, blood pressure 155/57, and o2 saturations 98% on room air. telemetry shows sinus rhythm. heent: pupils are equal and reactive to light and accommodation. extraocular movements are intact. neck: had no jugular venous distention. right carotid bruit. heart: apical impulse is normal. first and second sounds heard normally. he had a soft ejection systolic murmur. lungs: normal chest expansion, with clear to auscultation bilaterally. abdomen: soft, nontender, no palpable organomegaly. extremities: no edema, clubbing or cyanosis. cns: the patient is alert oriented x3, no focal neurological deficits. <strong>laboratory data:</strong> ekg shows sinus rhythm with right bundle-branch block, rate of 60. hemoglobin 9.6, hematocrit 29.3, and platelets 326,000. wbc 7.2. ck 67 and 59. troponin negative x 2. sodium 137, potassium 4.4, chloride 101, bicarbonate 28, bun 19, creatinine 2.1, and glucose 112. lfts were negative. bnp was 366. <strong>diagnostic data: </strong>ct showed chronic microvascular ischemic changes. ultrasound of the abdomen showed a small abdominal aortic aneurysm of 3.3 cm, no change from 2002. <strong>assessment and plan</strong> 1. syncope, suspect vasovagal in the setting of dehydration due to diuretics, diarrhea, and her blood medications. a recent echocardiogram has been done, which showed mildly depressed left ventricular systolic function, ejection fraction between 45% and 50%. at this time, we would rehydrate with iv fluids and reassess. 2. coronary artery disease, status post coronary artery bypass surgery, clinically stable with no angina. 3. history of pulmonary embolism in the past with presentation similar to this. in view of this history although her clinical presentation is atypical, would do a v/q scan to exclude this. 4. history of iron deficiency anemia, probably secondary to chronic kidney disease followed by dr. y, receiving procrit injections. 5. chronic kidney disease, baseline creatinine usually in the 1.8 to 1.9 range, today it is 2.1. we will reassess after iv fluids. 6. hypertension, continue current medications. 7. hypothyroidism, on replacement."
+"chief complaint:1.  extensive stage small cell lung cancer.2.  chemotherapy with carboplatin and etoposide.3.  left scapular pain status post ct scan of the thorax. history of present illness:  the patient is a 67-year-old female with extensive stage small cell lung cancer.  she is currently receiving treatment with carboplatin and etoposide.  she completed her fifth cycle on 08/12/10.  she has had ongoing back pain and was sent for a ct scan of the thorax.  she comes into clinic today accompanied by her daughters to review the results. current medications:  levothyroxine 88 mcg daily, soriatane 25 mg daily, timoptic 0.5% solution b.i.d., vicodin 5/500 mg one to two tablets q.6 hours p.r.n. allergies:  no known drug allergies. review of systems:  the patient continues to have back pain some time she also take two pain pill.  she received platelet transfusion the other day and reported mild fever.  she denies any chills, night sweats, chest pain, or shortness of breath.  the rest of her review of systems is negative. physical exam:vitals:    bp:  118/60.  heart rate:  76.  temp:  97.8.  weight:  65.5 kg.gen:      she looks well, in no acute distress.heent:    her pupils were noted for surgical changes bilaterally.  oropharynx is clear.neck:    supple.  she has no cervical or supraclavicular adenopathy.lungs:    clear to auscultation bilaterally.cv:    regular rate; normal s1, s2, no murmurs.abdomen:    soft.  he has positive bowel sounds.ext:    lower extremities are without edema. imaging:  her ct scan shows a pleural base mass in the left apex appears to have some growth along the medial margin comparing with pet/ct assessment 07/08/10.  while this extends to the pleural surface it does not clearly invade directly into the chest wall or the adjacent posterior lateral left third rib.  left suprahilar and mediastinal adenopathy appears to be essentially stable since 07/08/10.  multilevel thoracic bony metastatic disease is present.  hypodense liver metastasis appears slightly improved comparing with july, more substantially improved comparing with chest ct of 04/21/10. assessment/plan:  this is a very pleasant female 67-year-old female with extensive stage small cell lung cancer.  she had one treatment postponed due to counts.  she had low blood counts this week requiring platelet transfusion, so we are going to dose reduce for six treatments by 10%.  as far as the back pain, she clearly has evidence of progressive bone metastasis in t3, t11, t12, and t1 and questions about the soft tissue mass pleural base mass in the lateral left apex.  i am going to refer back to dr. x to see if there might be some palliative radiation to deal with the left back and scapular region."
+"procedures performed:  esophagogastroduodenoscopy. preprocedure diagnosis:  dysphagia. postprocedure diagnosis:  active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm. procedure:  informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  supplemental o2 given.  specifics of the procedure discussed.  the procedure was discussed with father and mother as the patient is mentally challenged.  he has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  he went to the emergency department yesterday with beef jerky. all of this reviewed.  the patient is currently on cortef, synthroid, tegretol, norvasc, lisinopril, ddavp.  he is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  he has not yet undergone significant workup.  he has not yet had an endoscopy or barium study performed.  he is developmentally delayed due to the surgery, panhypopituitarism. his family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  the patient does not smoke, does not drink.  he is living with his parents.  since his emergency department visitation yesterday, no significant complaints. large male, no acute distress.  vital signs monitored in the endoscopy suite.  lungs clear.  cardiac exam showed regular rhythm.  abdomen obese but soft.  extremity exam showed large hands.  he was a mallampati score a, asa classification type 2. the procedure discussed with the patient, the patient&#8217;s mother.  risks, benefits, and alternatives discussed.  potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  the potential need for a barium swallow, modified barium swallow, and similar discussed.  all questions answered.  at this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  he may have reflux symptoms, without complaining of heartburn.  he may benefit from a trial of ppi.  all of this reviewed.  all questions answered."
+"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 &quot;asleep&quot; 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&#038;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&#8217;s test not documented. gait: unsteady wide-based. able to tt and hw. poor tw. reflexes: 3/3 bue. hoffman&#8217;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."
+"clinical history:  this is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia. pertinent medications:  include tylenol, robitussin, colace, fosamax, multivitamins, hydrochlorothiazide, protonix and flaxseed oil. with the patient at rest 10.5 mci of cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained. procedure and interpretation:  the patient exercised for a total of 4 minutes and 41 seconds on the standard bruce protocol.  the peak workload was 7 mets.  the resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  the blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  ekg at rest showed normal sinus rhythm with a right-bundle branch block.  the peak stress ekg was abnormal with 2 mm of st segment depression in v3 to v6, which remained abnormal till about 6 to 8 minutes into recovery.  there were occasional pvcs, but no sustained arrhythmia.  the patient had an episode of supraventricular tachycardia at peak stress.  the ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 mets.  at peak stress, the patient was injected with 30.3 mci of cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images. myocardial perfusion imaging:1.  the overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.2.  there was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  this appeared to be partially reversible in the resting images.3.  the left ventricle appeared normal in size.4.  gated spect images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  the calculated ejection fraction was 70% at rest. conclusions:1.  average exercise tolerance.2.  adequate cardiac stress.3.  abnormal ekg response to stress, consistent with ischemia.  no symptoms of chest pain at rest.4.  myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.5.  the patient had run of svt at peak stress.6.  gated spect images revealed normal wall motion and normal left ventricular systolic function."
+"2-d study1. mild aortic stenosis, widely calcified, minimally restricted.2. mild left ventricular hypertrophy but normal systolic function.3. moderate biatrial enlargement.4. normal right ventricle.5. normal appearance of the tricuspid and mitral valves.6. normal left ventricle and left ventricular systolic function. doppler1. there is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.2. mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmhg maximum. summary1. normal left ventricle.2. moderate biatrial enlargement.3. mild tricuspid regurgitation, but only mild increase in right heart pressures."
+"ms. abcd is a 69-year-old lady, who was admitted to the hospital with chest pain and respiratory insufficiency.  she has chronic lung disease with bronchospastic angina. we discovered new t-wave abnormalities on her ekg.  there was of course a four-vessel bypass surgery in 2001.  we did a coronary angiogram.  this demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease. she may continue in the future to have angina and she will have nitroglycerin available for that if needed. her blood pressure has been elevated and so instead of metoprolol, we have started her on coreg 6.25 mg b.i.d.  this should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady&#8217;s case.  she also is on an ace inhibitor. so her discharge meds are as follows:1.  coreg 6.25 mg b.i.d.2.  simvastatin 40 mg nightly.3.  lisinopril 5 mg b.i.d.4.  protonix 40 mg a.m.5.  aspirin 160 mg a day.6.  lasix 20 mg b.i.d.7.  spiriva puff daily.8.  albuterol p.r.n. q.i.d.9.  advair 500/50 puff b.i.d.10.  xopenex q.i.d. and p.r.n. i will see her in a month to six weeks.  she is to follow up with dr. x before that."
+"subjective:  the patient is a 78-year-old female with the problem of essential hypertension.  she has symptoms that suggested intracranial pathology, but so far work-up has been negative. she is taking hydrochlorothiazide 25-mg once a day and k-dur 10-meq once a day with adequate control of her blood pressure.  she denies any chest pain, shortness of breath, pnd, ankle swelling, or dizziness. objective:  heart rate is 80 and blood pressure is 130/70.  head and neck are unremarkable.  heart sounds are normal.  abdomen is benign.  extremities are without edema. assessment and plan:  the patient reports that she had an echocardiogram done in the office of dr. sample doctor4 and was told that she had a massive heart attack in the past.  i have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, ekg, etc.  so, i advised her to have a chest x-ray and an ekg done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of dr. sample doctor4.  in the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup."
+"<strong>indications for procedure:</strong> persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis. <strong>premedication:</strong> 1. demerol 50 mg. 2. phenergan 25 mg. 3. atropine 0.6 mg im. 4. nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of versed was given at the start of the procedure and another 1 mg shortly after traversing the cords. <strong>procedure details:</strong> with the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the olympus bronchoscope was introduced through the right naris to the level of the cords. the cords move normally with phonation and ventilation. two times 2 ml of 1% lidocaine were instilled on the cords and the cords were traversed. further 2 ml of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. upper lobe and lingula were unremarkable. there appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. this had been a change from the prior bronchoscopy of unclear significance. distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. the scope was wedged in the left lower lobe posterior basal segment and a bal was done with good returns, which were faintly hemorrhagic. the scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. the scope was withdrawn. the patient&#8217;s saturation remained 93%-95% throughout the procedure. blood pressure was 103/62. heart rate at the end of the procedure was about 100. the patient tolerated the procedure well. samples were sent as follows. washings for afb, gram-stain nocardia, aspergillus, and routine culture. lavage for afb, gram-stain nocardia, aspergillus, cell count with differential, cytology, viral mycoplasma, and chlamydia culture, gms staining, rsv by antigen, and legionella and chlamydia culture."
+"reason for consultation:  loculated left effusion, multilobar pneumonia.    chief complaint/history of present illness:  the patient is a 67-year-old female who was admitted to the hospital on 12/22/09 when she had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.  post admission various measures were instituted to address her different manifestations including cardizem drip.  she had rehydration performed and also was given some diuretics.  ultimately there was improvement in her febrile status and renal status.  however most recently she had elevated white count and a repeat cat scan was performed.  this showed fluid collection in the left chest but also in the right chest.  the left fluid collection was also felt to be loculated. at the same time she was appearing to be quite ill with elevated white count, elevated temperature and for these reasons cardiothoracic consultation was obtained for addressing this fluid collection in the left chest.  past medical history:  significant for asthma, hypertension and history of pneumonias.  medications:  at home she was on symbicort, ibuprofen, prednisone and biaxin.  currently she is also on zyprexa, alcohol withdrawal medications, zosyn 3.375 grams every eight hours, lasix 20 mg daily, cardizem cd 120 mg daily, nexium 40 mg p.o. daily, solu-cortef 50 mg q.24h., lovenox 40 mg subcu daily, novolog sliding scale insulin.  social history:  alcohol drinking history, quit smoking about 30 years ago.  the patient is married.  allergies:  no known drug allergies.  review of systems:  no remarkable surgical history present.  the patient at this time appears confused and the chart review as well as talking to the son revealed most of the history.  apart from recent fevers and confusion the system review is negative.    examination:  on examination she is lying supine in bed, appears comfortable, awake, alert but is not oriented and is quite confused.  blood pressure is 110/70, heart rate is 80 per minute regular rhythm, saturations are 98 and 99% on four liters nasal cannula.  heent pupils equal, extraocular movements intact.  sclerae anicteric.  conjunctivae are pink and moist.  neck is supple.  trachea is midline.  thyroid is not enlarged. i  did not appreciate any neck masses or neck bruits.  bilateral crackles and rales in the mid lung fields more prominent on the left side and markedly diminished breath sounds especially in the left base.  s1, s2 regular rate and rhythm. no murmurs, rubs or gallops.  abdomen is soft, no organomegaly, nontender, normoactive bowel sounds.  extremities do not reveal cyanosis, clubbing or edema.  there is 1+ peripheral edema.    laboratory data:  review of lab data white count 13.4, hemoglobin 8.6 and hematocrit 25, platelet count 317.  bun and creatinine 10 and 0.9.  review of ct scan data infiltrate consolidation in multiple lobes of the lung both on the left side as well as at the right base.  right pleural effusion small layering at the base.  left pleural effusion appears to have loculations within the fissure as well as along the chest wall.  impression and plan:  the patient is a 67-year-old female who is recovering from multilobar pneumonia and is on antibiotics.  it appears she has had progression of her disease process in her left chest with now forming loculations.  we have been asked to consult for management of this pleural effusion.  after discussion with the patient&#8217;s son who would like to proceed in a step-wise fashion from least invasive to most invasive techniques, i counseled him that we should start with chest tube placement and this should be followed with activase instillation to try to break up the loculations, pending on the findings on the chest tube placement.  if necessary video assisted thoracoscopic procedure or open decortication can be performed."
+"reason for consultation:  cardiomyopathy and hypotension. history of present illness:  i am seeing the patient upon the request of dr. x.  the patient is very well known to me, an 81-year-old lady with dementia, a native american with coronary artery disease with prior bypass, reduced lv function, recurrent admissions for diarrhea and hypotension several times in november and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  because of her pre-existing coronary artery disease and cardiomyopathy with ef of about 30%, we were consulted to evaluate the patient.  the patient denies any chest pain or chest pressure.  denies any palpitations.  no bleeding difficulty.  no dizzy spells. review of systems:constitutional:  no fever or chills.eyes:  no visual disturbances.ent:  no difficulty swallowing.cardiovascular:  basically, no angina or chest pressure.  no palpitations.respiratory:  no wheezes.gi:  no abdominal pain, although she had diarrhea.gu:  no specific symptoms.musculoskeletal:  have sores on the back.neurologic:  have dementia.all other systems are otherwise unremarkable as far as the patient can give me information. past medical history:1.  positive for coronary artery disease for about two to three years.2.  hypertension.3.  anemia.4.  chronic renal insufficiency.5.  congestive heart failure with ef of 25% to 30%.6.  osteoporosis.7.  compression fractures.8.  diabetes mellitus.9.  hypothyroidism. past surgical history:1.  coronary artery bypass grafting x3 in 2008.2.  cholecystectomy.3.  amputation of the right second toe.4.  icd implantation. current medications at home:1.  amoxicillin.2.  clavulanic acid or augmentin every 12 hours.3.  clopidogrel 75 mg daily.4.  simvastatin 20 mg daily.5.  sodium bicarbonate 650 mg twice daily.6.  gabapentin 300 mg.7.  levothyroxine once daily.8.  digoxin 125 mcg daily.9.  fenofibrate 145 mg daily.10.  aspirin 81 mg daily.11.  raloxifene once daily.12.  calcium carbonate and alendronate.13.  metoprolol 25 mg daily.14.  brimonidine ophthalmic once daily. allergies:  she has no known allergies. family history:  noncontributory to this admission. social history:  she lives with husband, who is elderly, cannot take care of her.  she does not smoke or drink alcohol currently. physical examination:general:  elderly in no apparent distress.vital signs:  heart rate of 71, blood pressure 116/48.  upon presentation, her blood pressure was in the 80s.heent:  normocephalic and atraumatic.  no thyromegaly or lymphadenopathy.neck:  supple.cardiovascular:  carotid upstroke normal.  jugular venous pressure is about 7 cm of h2o.  the heart is irregularly irregular with a normal s1 and s2.  there is a 2/6 holosystolic murmur.lungs:  clear to auscultation.  no rales.abdomen:  benign.musculoskeletal:  no edema. laboratory tests:  hemoglobin of 8.7, hematocrit 25.7.  bun 111; creatinine of 5.0, prior creatinine of 1.88 on 11/30/2009.  troponin of 0.09 with very elevated myoglobin of 575.  the blood dipstick in the urine was moderate. assessment and plan:1.  elderly with rhabdomyolysis, acute renal insufficiency, secondary to diarrhea.  evaluate for c diff.2.  hydration.  increase fluids to about 200 an hour.  consult with nephrology.3.  hold off beta-blockers at this time until blood pressure is more stable.  may restart metoprolol 25 mg b.i.d.4.  no need for ef.  assessment plus ef is about 30% with mitral regurgitation on a very recent echocardiogram.5.  further recommendations will depend on the blood pressure over the next 24 hours."
+"procedure:  cardiac catheterization by:a.  left heart catheterization.b.  left ventriculography.c.  selective coronary angiography.d.  right femoral artery approach. complications:  none. medications1.  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. findingshemodynamicsleft 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 arteriography1.  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."
+"description of record:  this tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the international 10-20 system.  electrode impedances were measured and reported at less than 5 kilo-ohms each. findings:  in general, the background rhythms are bilaterally symmetrical.  during the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 hz alpha activity best seen posteriorly.  the alpha activity attenuates with eye opening. during some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity. there is no evidence of focal slowing or paroxysmal activity. impression:  normal awake and drowsy (stage i sleep) eeg for patient&#8217;s age."
+"<strong>reason for exam: </strong>right-sided abdominal pain with nausea and fever. <strong>technique: </strong>axial ct images of the abdomen and pelvis were obtained utilizing 100 ml of isovue-300. <strong>ct abdomen: </strong>the liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable. <strong>ct pelvis: </strong>within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant. findings are compatible with acute appendicitis. the large and small bowels are normal in course and caliber without obstruction. the urinary bladder is normal. the uterus appears unremarkable. mild free fluid is seen in the lower pelvis. no destructive osseous lesions are seen. the visualized lung bases are clear. <strong>impression: </strong>acute appendicitis."
+"procedure:  left cardiac catheterization, left ventriculography, coronary angiography and stent placement. indications:  atherosclerotic coronary artery disease. patient history:  this is a 55-year-old male.  he presented with 3 hours of unstable angina. past cardiac history:  history of previous arteriosclerotic cardiovascular disease.  previous st elevation mi. review of systems.  the creatinine value is 1.3 mg/dl mg/dl. procedure medications:1.  visipaque 361 ml total dose.2.  clopidogrel bisulphate (plavix) 225 mg po3.  promethazine (phenergan) 12.5 mg total dose.4.  abciximab (reopro) 10 mg iv bolus5.  abciximab (reopro) 0.125 mcg/kg/minute, 4.5 ml/250 ml d5w x 17 ml6.  nitroglycerin 300 mcg ic total dose. description of procedure:approach:  left heart catheterization via right femoral artery approach.access method:  percutaneous needle puncture. devices used:1.  balloon catheter utilized:  manufacturer:  boston sci quantum maverick rx 2.75mm x 20mm.2.  cordis vista brite tip 6fr jr 4.03.  acs/guidant sport .014&quot; (190cm) wire4.  stent utilized:  boston sci taxus rx stent 3.0mm x 32mm. findings/interventions:left ventriculography:  the overall left ventricular systolic function is mildly reduced.  left ventricular ejection fraction is 40% by left ventriculogram.  mild hypokinesis of the anterior wall of the left ventricle.  there was no transaortic gradient.  mitral valve regurgitation is not seen.left main coronary artery:    there were no obstructing lesions in the left main coronary artery.  blood flow appeared normal.left anterior descending artery:  there was a 95%, discrete stenosis in the mid left anterior descending artery.  a drug eluting, boston sci taxus rx stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm.  post-procedure stenosis was 0%.  there was no dissection and no perforation.left circumflex artery:  there was a 50%, diffuse stenosis in the left circumflex artery.right coronary artery:  the right coronary artery is dominant to the posterior circulation.  there were no obstructing lesions in the right coronary artery.  blood flow appeared normal. complications:there were no complications during the procedure. impression:1.  severe two-vessel coronary artery disease.2.  severe left anterior descending coronary artery disease.  there was a 95% mid left anterior descending artery stenosis.  the lesion was successfully stented.3.  moderate left circumflex artery disease.  there was a 50% left circumflex artery stenosis.  intervention not warranted.4.  the overall left ventricular systolic function is mildly reduced with ejection fraction of 40%.  mild hypokinesis of the anterior wall of the left ventricle. recommendation:1.  clopidogrel (plavix) 75 mg po daily for 1 year.2.  aggressive risk factor modification of tobacco abuse, hyperlipidemia and hypertension. cpt code(s):92980, ld, transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel. 93510, left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous. 93556, 59, imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass). 93555, 59, imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography. 93545, injection procedure during cardiac catheterization; for selective coronary angiography (injection of radiopaque material may be by hand). 93543, injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography. icd code(s):  414.01, coronary atherosclerosis of native coronary artery."
+"reason for referral:  ms. a is a 60-year-old african-american female with 12 years of education who was referred for neuropsychological evaluation by dr. x after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in july.  a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. relevant background information:  historical information was obtained from a review of available medical records and clinical interview with ms. a.  a summary of pertinent information is presented below.  please refer to the patient&#8217;s medical chart for a more complete history. history of presenting problem:  ms. a presented to the abc hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  neurological evaluation with dr. x confirmed left hemiparesis.  brain ct showed no evidence of intracranial hemorrhage or mass effect and that she received tpa and had moderate improvement in left-sided weakness.  these symptoms were thought to be due to a right middle cerebral artery stroke.  she was transferred to the icu for monitoring.  ultrasound of the carotids showed 20% to 30% stenosis of the right ica and 0% to 19% stenosis of the left ica.  on 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right mca/cva.  at discharge on 08/06/2009, she was mainly on supervision for all adls and walking with a rolling walker, but tolerating increased ambulation with a cane.  she was discharged home with recommendations for outpatient physical therapy.  she returned to the sinai er on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt &quot;just like the stroke.&quot;  brain ct on 08/2009/2009 was read as showing &quot;mild chronic microvascular ischemic change of deep white matter,&quot; but no acute or significant interval change compared to her previous scan.  neurological examination with dr. y was within normal limits, but she was admitted for a more extensive workup.  due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis. followup ct on 08/10/2009 showed no significant interval change.  mri could not be completed due to the patient&#8217;s weight.  she was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that ms. a referred to this as a second stroke. ms. a presented for a followup outpatient neurological evaluation with dr. x on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  she demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  during the current interview, ms. a reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  she also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  when asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  she reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the social security agency that she works at.  note also that she had some difficulty explaining exactly what her job involved.  she also reported having problems falling asleep at work and that she is working full-time although on light duty. other medical history:  as mentioned, ms. a continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  she was diagnosed with sleep apnea approximately two years ago and was recently counseled by dr. x on the need to use her cpap because she indicated she never used it at night.  she reported that since her appointment with dr. x, she has been using it &quot;every other night.&quot;  when asked about daytime fatigue, ms. a initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  she reported at times &quot;snoring&quot; and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  she receives approximately two to five hours of sleep per night.  other current untreated risk factors include obesity and hypercholesterolemia.  her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke). current medications:  aspirin 81 mg daily, colace 100 mg b.i.d., lipitor 80 mg daily, and albuterol mdi p.r.n. substance use:  ms. a denied drinking alcohol or using illicit drugs.  she used to smoke a pack of cigarettes per day, but quit five to six years ago. family medical history:  ms. a had difficulty providing information on familial medical history.  she reported that her mother died three to four years ago from lung cancer.  her father has gout and blood clots.  siblings have reportedly been treated for asthma and gi tumors.  she was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc. social history:  ms. a completed high school degree.  she reported that she primarily obtained b&#8217;s and c&#8217;s in school.  she received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity. she currently works for the social security administration in data processing.  as mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  she is now living on her own.  she has never driven.  she reported that she continues to perform adls independently such as cooking and cleaning.  she lost her husband in 2005 and has three adult daughters.  she previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  she also reported number of other family members who had recently passed away.  she has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the bahamas at the end of october. psychiatric history:  ms. a did not report a history of psychological or psychiatric treatment.  she reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  she reported that this only &quot;comes and goes.&quot; tasks administered:clinical interviewadult history questionnairewechsler test of adult reading (wtar)mini mental status exam (mmse)cognistat neurobehavioral cognitive status examinationrepeatable battery for the assessment of neuropsychological status (rbans; form xx)mattis dementia rating scale, 2nd edition (drs-2)neuropsychological assessment battery (nab)wechsler adult intelligence scale, third edition (wais-iii)wechsler adult intelligence scale, fourth edition (wais-iv)wechsler abbreviated scale of intelligence (wasi)test of variables of attention (tova)auditory consonant trigrams (act)paced auditory serial addition test (pasat)ruff 2 &#038; 7 selective attention testsymbol digit modalities test (sdmt)multilingual aphasia examination, second edition (mae-ii)  token test  sentence repetition  visual naming  controlled oral word association  spelling test  aural comprehension  reading comprehensionboston naming test, second edition (bnt-2)animal naming testcontrolled oral word association test (cowat:  f-a-s)the beery-buktenica developmental test of visual-motor integration (vmi)the beery-buktenica developmental test of motor coordinationthe beery-buktenica developmental test of visual perceptionhooper visual organization test (vot)judgment of line orientation (jolo)rey complex figure test (rcft)wechsler memory scale, third edition (wms-iii)wechsler memory scale, fourth edition (wms-iv)california verbal learning test, second edition (cvlt-ii)rey auditory-verbal learning test (ravlt)delis-kaplan executive function system (d-kefs)  trail making test  verbal fluency (letter &#038; category)  design fluency  color-word interference test  towerwisconsin card sorting test (wcst)stroop color-word testcolor trailstrail making test a &#038; bwide range achievement test, fourth edition (wrat-iv)woodcock johnson tests of achievement, third edition (wj-iii)nelson-denny reading testgrooved pegboardpurdue pegboardfinger tapping testbeck depression inventory (bdi)mood assessment scale (mas)state-trait anxiety inventory (stai)minnesota multiphasic personality inventory, second edition (mmpi-2)millon clinical multiaxial inventory, third edition (mcmi-iii)millon behavioral medicine diagnostic (mbmd)behavior rating inventory of executive function (brief)adaptive behavior assessment system, second edition (abas-ii) behavioral observations:  ms. a arrived alone and on time for her appointment.  she walked with a cane and was short of breath while walking.  no other significant psychomotor abnormalities were noted.  vision and hearing appeared to be adequate for testing, although she did indicate that she needed to update her eyeglass prescription.  she was appropriately dressed and groomed.  rapport was easily established and eye contact was appropriate.  she was oriented to person and place, but not fully oriented to time as she said that it was monday rather than tuesday.  she was very talkative and speech tended to be somewhat disorganized and circumstantial.  she had difficulty answering questions in a concise and succinct manner with notable difficulties in generalizing her experience (e.g. tended to respond to general questions in a very specific manner with a high level of detail).  she would at times talk while completing tasks and was reminded to focus on the task at hand.  receptive language abilities appeared to be within broad normal limits as she was able to appropriately respond to the examiner&#8217;s questions and instructions. thought processes were somewhat circumstantial as already noted, but no overt thought disturbances were noted.  mood appeared to be euthymic.  affect was full ranged.  she was noted to be somewhat impulsive and disinhibited and the vowel receptive language abilities were intact.  in general, she had difficulty responding to more abstract or general questions.  she was noted to be very tired throughout the evaluation.  she said that she fell asleep during a sustained attention task, although this was not noted by the examiner.  the examiner did observe her falling asleep at points during task instructions and she also slept in the lobby throughout lunchtime and had to be awoken to resume testing.  her fatigue likely affected her performance on certain tasks. overall, ms. a appeared to put full effort into all the tasks during this evaluation although as noted her fatigue likely impacted her performance to some degree and these test results will be interpreted with that in mind.  the patient did not recognize this examiner when she returned for this evaluation. general cognitive ability:  premorbid intellectual functioning as assessed with the word reading test fell in the average to low average range.  her performances on measures assessing current intellectual functioning suggested some weaknesses in stored verbal knowledge and both verbal and visual abstract reasoning (all borderline).  visuospatial construction was in the low average range. attention:  ms. a demonstrated weaknesses in certain aspects of attention and concentration.  for auditory verbal information, she was able to accurately process basic immediate information, but had more difficulty when active attentional abilities were required and she had to manipulate information in mind.  on visually-based tasks, again simple attentional abilities such as visual scanning and basic processing of information were within the average range; however, it was noted that there was a trade-off between speed and accuracy in her performances on more complex attentional tasks that required greater levels of focus as she tended to complete the task slowly in order to accurately discriminate between target and nontarget visual stimuli.  on a visual sustained attention task, her overall number of errors and response rate were within broad normal limits, but it was noted that her response speed slowed and the accuracy of her responses became less consistent as the test progressed suggesting weaknesses in vigilance.  it was also noted that she was slower to respond and there was more variability in response accuracy when stimuli were presented with longer interstimulus intervals suggesting some weaknesses in arousal and activation when information was presented at a slower rate.  taking together these results highlight deficits in working memory (e.g. complex attention and mental manipulation), sustained attention and vigilance while her more basic and immediate attentional abilities were within broad normal limits.  fatigue was likely a factor in these results.  it is unlikely that ms. a actually fell asleep during this task as her error rate is not very high; however, there were noted decreases in measures that are sensitive to arousal and activation. information processing speed:  as mentioned, ms. a tended to perform within expected limits on brief verbal and visual tasks that involved basic processing.  she had more difficulty maintaining consistency in her response rate and tended to become slower on tasks that require sustained attention and more complex discrimination of stimuli. language:  confrontation naming was in the impaired range, but this may be in part due to lack of familiarity with certain objects given her weak performance on tasks assessing stored verbal knowledge.  minor errors were noted on sentence repetition task, but this may be due to weaknesses in attention and working memory. similarly, her low average performance on a verbal comprehension task may have been due to some weaknesses in vigilance as she was noted to fall asleep at times during this task.  verbal fluency for both phonemic and semantic cues was within the average range.  as taken together some weaknesses in aspects of language appear to have been due to limitations in attention and verbal knowledge store. visuospatial perception and organization:  ms. a performed within the average range and within expected limits on visuospatial construction tasks that involved matching to a sample using either blocks or drawing; however, she had notable difficulties when we attempted to assess her perception of angular line orientations.  these results suggest some reliance on external cues and information for accurate interpretation of visuospatial stimuli and difficulty with perception when such cues are not present to structure her perception.  note that fatigue may have also been a factor here as well. learning &#038; memory skills:   verbal learning and memory:  on contextual memory task (i.e. stories), ms. a performed in the borderline range in immediate recall.  following a delay, she retained 62% of the information that she originally learned and recall was again in the borderline range.  delayed recognition was low average.  on a task assessing her ability to learn large amounts of seemingly unorganized information (i.e. list), her initial acquisition of information was in the low average range.  with repetition, her performance improved and her overall immediate learning fell in the average range.  following a short delay, she was only able to spontaneously recall about a third of the information that she had initially learned and her overall performance fell in the borderline range.  with cueing, she was able to recall more information, but relative to her same age peers this performance still fell in the borderline range.  recall following a long delay was in the borderline to low average range and recognition was borderline as she did not recognize a number of the original target stimuli.  of note, she made a number of repetitions and intrusion errors some of which were semantically related to the list target items and were repeatedly given suggesting some difficulty in correcting her responses with feedback and in monitoring or organizing her responses.  taken together these results highlight difficulties in learning large amounts of verbal information due primarily to difficulties with the initial organizing or learning of the information, although some weaknesses in retrieval were also noted.  these results are likely due to the above noted attention and working memory deficits as she was able to at least recognize most of the information that she had initially learned.   non-verbal/visual learning and memory:  ms. a&#8217;s initial recall of the details in spatial location of the series of visual designs is in the low average range.  she retained most of this information following a delay with recall and recognition falling in the average range.  immediate recall of a complex figure drawing was in the average range.  following a 30-minute delay, she retained most of this information although statistically her result fell in the low average range.  recognition of the individual component parts of the larger figure fell in the low average range.  taken together these results suggest that ms. a was mildly limited in the amount of information that she could initially learn, but the fact that she was able to retain most of that information over time suggests that any difficulties in learning visual information occurred during initial encoding.  this pattern of results is similar to those found for verbal information. executive functioning:  ms. a performed within the low average-to-average range on tasks assessing verbal fluency, cognitive set shifting, and inhibition of prepotent responses; however, it should be noted that ms. a made a number of errors on these tasks particularly for inhibition, although she was able to successfully correct those errors. across tasks and during interactions it was noted that ms. a had some weaknesses in organization.  visual and verbal abstract reasoning were in the borderline range and deficits in working memory were noted.  taken together these results highlight some weaknesses in executive functioning. motor/psychomotor functioning:  ms. a performed in the impaired range with her dominant right hand and her nondominant hand on a task assessing speeded fine motor coordination. emotional functioning:  ms. a&#8217;s overall score on a self-report effective screening measure suggested that she is currently experiencing mild levels of depression.  she endorsed symptoms related to dysphoria, anxiety, lack of energy, anhedonia, hopelessness, and cognitive problems. summary &#038; impressions:  ms. a was referred for a neuropsychological evaluation by dr. x, m.d. to follow up noted cognitive weaknesses following a right middle cerebral artery stroke that was seen on a neuropsychological screening.  test results suggested that ms. a was premorbidly performing in the low average to average range.  based on this estimate, she performed within expected limits on tasks assessing immediate attention and speed for processing brief, simple, and straightforward information.  most aspects of language (i.e. repetition, comprehension, and fluency), and visuospatial construction (i.e. matching to sample).  deficits were seen primarily in the areas of complex attention or working memory and sustained attention.  she had difficulty mentally manipulating information in mind and on longer task that required focus.  she demonstrated poor vigilance, difficulty with discrimination of stimuli, and declines in arousal and activation.  these attentional deficits affected her ability to learn verbal and visual information.  weaknesses in executive functioning were also noted based on her performances across tasks as well as behavioral observations as she demonstrated weaknesses in abstract thinking, organization, inhibition, and behavioral and response regulation.  combined with the deficits seen for fine motor skills, these results are consistent with frontal subcortical changes as were seen on her cat scan.  in addition, ms. a demonstrated some difficulty completing a task that involved interpreting directionally based visuospatial stimuli in the absence of other cues to aid with perception and these findings may be consistent with the involvement of the right hemisphere in her recent stroke; however, given that no mri was conducted it is difficult to say whether or not there are specific regions of infarct in her right hemisphere. overall, these results are consistent with those seen on her recent neuropsychological screening.  this evaluation was requested in order to further clarify those results.  as noted above, ms. a does have a number of areas of deficit; however, these results do not support a dementing process at this time.  the pattern of findings as mentioned are consistent with subcortical changes, but may also be secondary to her poorly treated sleep apnea as she was noticeably tired and particular deficits were noticed on tasks that required complex or sustained attention.  thus it will be important for ms. a to increase compliance with treatment for sleep apnea and also to ensure that other cardiovascular risk factors are monitored and controlled through diet, exercise, and medication.  given that she is working full-time and these cognitive deficits could create significant problems on the job, it will be important that ms. a address these issues while she is still completing a lighter load at work.  additional recommendations are provided below. recommendations:1.  it is imperative that ms. a address her sleep apnea and comply consistently i.e. every evening with wearing her cpap.  given that she continues to complain about it and report the claustrophobia prevents her from using it regularly, ms. a should see a sleep specialist in order to determine alternate ways to address this problem.2.  ms. a reported mild levels of depression and anxiety on this evaluation and it was previously recommended that she contact xyz to inquire about counseling and management of multiple life stressors.3.  ms. a should see an ophthalmologist to update her eyeglass prescription.  it may have contributed to the noted deficits on one visuospatial task.4.  continued pt and home exercises i recommended to improve physical abilities.5.  ms. a is likely not obtaining enough physical exercise and it is suggested that she work with her physical therapist and primary care physician to determine exercise regimen in order to help her lose weight.6.  the following recommendations are provided to aid ms. a with the noted difficulties with attention and memory.  she may also benefit from cognitive therapy in order to learn to apply these strategies at work.7.  ms. a&#8217;s cardio and cerebrovascular risk factors should be closely monitored and the results of this evaluation should be shared with all of her physicians. thank you for referring this interesting patient for evaluation.  a neuropsychological reevaluation is recommended in one to two years in order to monitor cognitive functioning.  reevaluation should occur earlier if there is any worsening of cognitive functioning."
+"informed consent was obtained from the patient after the risks and benefits of the procedure were explained.  the risks that were explained were bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing small polyps within the colon.  conscious sedation was achieved with the patient lying in the left lateral decubitus position. a colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve.  this was done without difficulty and the bowel preparation was good.  the ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal.  the colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed. complications:  none."
+"the patient was identified.  risks, benefits, and alternatives of the procedure were discussed with the patient.  the patient understood, was consented, brought in the procedure room, and connected to the appropriate monitoring devices.  versed and fentanyl were given in divided doses.  after appropriate sedation was achieved, a digital rectal examination was done and was normal.  a well-lubricated colonoscope was then inserted and advanced under direct visualization to the level of the cecum.  a picture was taken at the level of the cecum and the colonoscope was then slowly withdrawn.  after the procedure was done, the colonoscope was removed, and the patient was returned to the recovery room in stable condition.  there were no complications."
+"reason for visit:  six-month follow-up visit for cad. he is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and djd. he has been having a lot of pain in his back and pain in his left knee.  he is also having trouble getting his nerves under control.  he is having stomach pains and occasional nausea.  his teeth are bad and need to be pulled. he has been having some chest pains, but overall he does not sound too concerning.  he does note some more shortness of breath than usual.  he has had no palpitations or lightheadedness.  no problems with edema. medications:  lipitor 40 mg q.d., metoprolol 25 mg b.i.d., plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, lorcet 10/650-given a 60 pill prescription, and xanax 0.5 mg b.i.d-given a 60 pill prescription. review of systems:  otherwise unremarkable. pex:  bp:  140/78.  hr:  65.  wt:  260 pounds (which is up one pound).  there is no jvd.  no carotid bruit.  cardiac:  regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border.  lungs:  clear.  abdomen:  mildly tender throughout the epigastrium.extremities:  no edema. ekg:  sinus rhythm, left axis deviation, otherwise unremarkable. echocardiogram (for dyspnea and cad):  normal systolic and diastolic function.  moderate lvh.  possible gallstones seen. impression:1.  cad-status post anterior wall mi 07/07 and was found to a have multivessel cad.  he has a stent in his lad and his obtuse marginal.  fairly stable.2.  dyspnea-seems to be due to his weight and the disability from his knee.  his echocardiogram shows no systolic or diastolic function.3.  knee pain-we well refer to scotland orthopedics and we will refill his prescription for lorcet 60 pills with no refills.4.  dyslipidemia-excellent numbers today with cholesterol of 115, hdl 45, triglycerides 187, and ldl 33, samples of lipitor given.5.  panic attacks and anxiety-xanax 0.5 mg b.i.d., 60 pills with no refills given.6.  abdominal pain-asked to restart his omeprazole and i am also going to reduce his aspirin to 81 mg q.d.7.  prevention-i do not think he needs to be on the plavix any more as he has been relatively stable for two years. plan:1.  discontinue plavix.2.  aspirin reduced to 81 mg a day.3.  lorcet and xanax prescriptions given.4.  refer over to scotland orthopedics.5.  peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted."
+"clinical history: this 78-year-old black woman has a history of hypertension, but no other cardiac problems. she noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. she was evaluated by her pcp on january 31st and her ecg showed sinus bradycardia with a rate of 37 beats per minute. she has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. an echocardiogram showed an ejection fraction of 70% without significant valvular heart disease. procedure: implantation of a dual chamber permanent pacemaker. approach: left cephalic vein. leads implanted: medtronic model 5076-45 in the right atrium, serial number pjn983322v. medtronic 5076-52 in the right ventricle, serial number pjn961008v. device implanted: medtronic enrhythm model p1501vr, serial number pnp422256h. lead performance: atrial threshold less than 1.3 volts at 0.5 milliseconds. p wave 3.3 millivolts. impedance 572 ohms. right ventricle threshold 0.9 volts at 0.5 milliseconds. r wave 10.3. impedance 855. estimated blood loss: 20 ml. complications: none. description of procedure: the patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with versed and fentanyl. the left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. a 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. the deltopectoral groove was explored and a medium-sized cephalic vein was identified. the distal end of the vein was ligated and a venotomy was performed. two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. the venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. the right ventricular lead was placed in the high rv septum and the right atrial lead was placed in the right atrial appendage. the leads were tested with a pacing systems analyzer and the results are noted above. the leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. the pacemaker was noted to function appropriately. the pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. the incision was closed with two layers of 3-0 monocryl and a subcuticular closure of 4-0 monocryl. the incision was dressed with steri-strips and a sterile bandage and the patient was returned to her room in good condition. impression: successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. the patient will be observed overnight and will go home in the morning."
+"reason for consultation:  pulmonary embolism. history:  the patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  the patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  at that time, her daughter was with her.  no tonic-clonic movements.  no cyanosis.  the patient woke up on her own.  the patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  she cannot get up one flight of stairs, but feels short of breath.  she gets exerted and thinks to take a shower.  she does not have any chest pain, no fever or syncopal episodes. past medical history1.  pulmonary embolism diagnosed one year ago.  at that time, she has had an ivc filter placed due to massive gi bleed from diverticulosis and gastric ulcers.  paroxysmal atrial fibrillation and no anticoagulation due to history of gi bleed.2.  coronary artery disease status post cabg at that time.  she has had to stay in the icu according to the daughter for 3 weeks due to again lower gi bleed.3.  mitral regurgitation.4.  gastroesophageal reflux disease.5.  hypertension.6.  hyperlipidemia.7.  history of aortic aneurysm.8.  history of renal artery stenosis.9.  peripheral vascular disease.10.  hypothyroidism. past surgical history1.  cabg.2.  hysterectomy.3.  ivc filter.4.  tonsillectomy.5.  adenoidectomy.6.  cosmetic surgery.7.  renal stent.8.  right femoral stent. home medications1.  aspirin.2.  potassium.3.  lasix.4.  levothyroxine.5.  lisinopril.6.  pacerone.7.  protonix.8.  toprol.9.  vitamin b.10.  zetia.11.  zyrtec. allergies:  sulfa social history:  she used to be a smoker, not anymore.  she drinks 2 to 3 glasses of wine per week.  she is retired. review of systems:  she has a history of snoring, choking for breath at night, and dry mouth in the morning. physical examinationgeneral appearance:  in no acute distress.vital signs:  temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.heent:  no lymph nodes or masses.neck:  no jugular venous distension.lungs:  clear to auscultation bilaterally.heart:  regular rate and rhythm.abdomen:  soft and nontender.extremities:  no lower extremity edema.  no redness or hotness.neurologic:  the patient is alert and oriented x3. laboratory:  labs showed creatinine 2.1 and hemoglobin 9.6.  chest x-ray was clear.  v/q scan was normal. assessment and plan1.  pulmonary embolism with contraindication to anticoagulation due to recurrent gastrointestinal bleed, status post ivc filter.  no evidence of chronic thromboembolic disease per v/q scan.  we cannot rule out pulmonary hypertension.2.  shortness of breath upon exertion.  the patient will need a pft as an outpatient.  chest x-ray is clear.  we will do oxygen saturation with ambulation to rule out that as a source of loss of consciousness.3.  mitral valve disease, coronary artery disease, and peripheral vascular disease per cardiology.4.  probable sleep apnea; will need a sleep study as an outpatient."
+"discharge diagnosis:1.  respiratory failure improved.2.  hypotension resolved.3.  anemia of chronic disease stable.4.  anasarca improving.5.  protein malnourishment improving.6.  end-stage liver disease. history and hospital course:  the patient was admitted after undergoing a drawn out process with a small bowel obstruction.  his bowel function started to improve.  he was on tpn prior to coming to hospital.  he has remained on tpn throughout his time here, but his appetite and his p.o. intake have improved some.  the patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the intensive care unit on dopamine.  at one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  the patient also was requiring bipap to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  this has been treated successfully with zyvox and levaquin and diflucan.  he seems to be currently doing much better.  he is only using bipap in the evening.  as stated above, he is eating better.  he had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  this may be mainly dependent edema versus anasarca.  the patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  this morning, the patient denies any acute distress.  he states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  he will be discharged to garden court skilled nursing facility. discharge medications/instructions:  he is going to be going with protonix 40 mg daily, metoclopramide 10 mg every 6 hours, zyvox 600 mg daily for 5 days, diflucan 150 mg p.o. daily for 3 days, bumex 2 mg p.o. daily, megace 400 mg p.o. b.i.d., ensure 1 can t.i.d. with meals, and miralax 17 gm p.o. daily.  the patient is going to require physical therapy to help with assistance in strength training.  he is also going to need respiratory care to work with his bipap.  his initial settings are at a rate of 20, pressure support of 12, peep of 6, fio2 of 40%.  the patient will need a sleep study, which the nursing home will be able to set up. physical examination:vital signs:  on the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, o2 sat 97%.general:  a well-developed white male who appears in no apparent distress.heent:  unremarkable.cardiovascular:  positive s1, s2 without murmur, rubs, or gallops.lungs:  clear to auscultation bilaterally without wheezes or crackles.abdomen:  positive for bowel sounds.  soft, nondistended.  he does have some generalized redness around his abdominal region and groin.  this does appear improved compared to presentation last week.  the swelling in this area also appears improved.extremities:  show no clubbing or cyanosis.  he does have some lower extremity edema, 2+ distal pedal pulses are present.neurologic:  the patient is alert and oriented to person and place.  he is alert and aware of surroundings.  we have not had any difficulties with confusion here lately.musculoskeletal:  the patient moves all extremities without difficulty.  he is just weak in general. laboratory data:  lab work done today shows the following:  white count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  electrolytes show sodium 139, potassium 4.1, chloride 98, co2 26, glucose 79, bun 56, and creatinine 1.4.  calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9. plan:  discharge this gentleman from hospital and admit him to garden court snf where they can continue with his rehab and conditioning.  hopefully, long-term planning will be discharge home.  he has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  the family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time."
+"procedure:  left heart catheterization, left ventriculography, selective coronary angiography. indication:  this lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  this was felt to be related largely to chronic obstructive lung disease.  she had dynamic t-wave changes in precordial leads.  cardiac enzymes were indeterminate.  she was evaluated by dr. x and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography. risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  the patient understood and agreed to proceed. description of the procedure:  the patient was brought to the cardiac catheterization laboratory.  under versed and fentanyl sedation, the right groin was sterilely prepped and draped.  local anesthesia was obtained with 2% xylocaine.  the right femoral artery was entered using modified seldinger technique and a 4-french introducer sheath placed in that vessel.  through the indwelling femoral arterial sheath, a jl4 4-french catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  ascending aortic root pressures obtained.  this catheter was utilized in an attempt to cannulate the left coronary ostium.  this catheter was too small, was exchanged for a jl5 4-french catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained. this catheter was then exchanged for a 4-french right coronary catheter, which was advanced over the wire to the ascending aorta.  the catheter appropriately aspirated and flushed.  the catheter was advanced in the right coronary artery.  multiple views of that vessel were obtained.  the catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  this catheter was then exchanged for a 4-french pigtail catheter, which was advanced over the wire to the ascending aorta.  the catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained. following this, left ventriculography was performed in a 30-degree rao projection using 30 ml of contrast injected over 3 seconds.  post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  videotapes were then reviewed.  it was elected to terminate the procedure at that point in time. the vascular sheath was removed and manual compression carried out.  excellent hemostasis was obtained.  the patient tolerated the procedure without complication. results of procedure1.  hemodynamics:  left ventricular end-diastolic filling pressure was 24.  there was no gradient across the aortic valve.2.  left ventriculography:  left ventriculography demonstrated well-preserved left ventricular systolic function.  mild inferobasilar hypokinesis was noted.  no significant mitral regurgitation noted.  ejection fraction was estimated at 60%.3.  coronary arteriographya.  left main coronary:  the left main coronary was patent.b.  left anterior descending coronary artery:  left anterior descending coronary was occluded shortly after a very small first septal perforator was given.c.  circumflex coronary artery:  circumflex coronary artery was occluded at its origin.d.  right coronary artery.  right coronary artery was occluded in its mid portion.4.  saphenous vein graft angiographya.  saphenous vein graft to the diagonal branch:  the saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  excellent flow was noted in the diagonal system with some retrograde flow.b.  there was retrograde flow as well in the left anterior descending system.c.  saphenous vein graft to the obtuse marginal system:  saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  there was no graft disease noted.  excellent flow was noted in the bifurcating marginal system.d.  saphenous vein graft to right coronary artery:  saphenous vein graft to right coronary was widely patent with no graft disease.  origin and insertion sites were free of disease.  distal flow in the graft to the posterior descending was normal.5.  left internal mammary artery angiography:  left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  there was no focal disease noted, inserted into the mid-to-distal lad which was a small-caliber vessel.  retrograde filling of a small septal system was noted. summary of results1.  elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.2.  occluded native right coronary, left anterior descending, and circumflex coronary arteries.3.  widely patent saphenous vein graft to the right coronary artery, obtuse marginal system, diagonal system.4.  widely patent left internal mammary artery and left anterior descending. recommendations:  the patient needs no additional cardiovascular evaluation or workup.  her full-dose lovenox should be discontinued and low-dose lovenox for dvt prophylaxis should be carried out.  the usual medications for risk control and medicines for diabetic control will be appropriate."
+"name of procedure:  left heart catheterization with ventriculography, selective coronary angiography. indications:  acute coronary syndrome. technique of procedure:  standard judkins, right groin.  catheters used were a 6 french pigtail, 6 french jl4, 6 french jr4.   anticoagulation:  the patient was on heparin at the time. complications:  none. i reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, atn allergy, need for cardiac surgery.  all questions were answered, and the patient desired to proceed. hemodynamic data:  aortic pressure was in the physiologic range.  no significant gradient across the aortic valve. angiographic data1. ventriculogram:  the left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.2. right coronary artery:  dominant.  there was insignificant disease in the system.3. left coronary:  left main, left anterior descending and circumflex systems showed no significant disease. conclusions1. normal left ventricular systolic function.2. insignificant coronary disease. plan:  based upon this study, medical therapy is warranted.  six-french angio-seal was used in the groin."
+"reason for consult:  i was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior st-elevation mi. history of present illness:  the patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion.  her daughter who accompanies her is very attentive whom i had met previously during drainage of a malignant hemorrhagic pericardial effusion last month.  the patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m.  at about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements.  her daughter called 911 and her symptoms seemed to improve.  then, she began vomiting.  when the patient&#8217;s daughter asked her if she had chest pain, the patient said yes. she came to the emergency room, an ekg showed inferior st-elevation mi.  i was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, i felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with pci/cabg.  she was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free.  repeat ekg shows normalization of her st elevation in the inferior leads as well as normalization of prior reciprocal changes. past medical history:  significant for metastatic non-small-cell lung cancer.  in early-to-mid december, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage.  we did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion.  she is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple cva. medications:  medications as an outpatient:1.  amiodarone 200 mg once a day.2.  roxanol concentrate 5 mg three hours p.r.n. pain. allergies:  codeine.  no shrimp, seafood, or dye allergy. family history:  negative for cardiac disease. social history:  she does not smoke cigarettes.  she uses alcohol.  no use of illicit drugs.  she is divorced and lives with her daughter.  she is a retired medical librarian from florida. review of systems:  unable to be obtained due to the patient&#8217;s aphasia. physical examination:  height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22.  o2 saturation 100%.  on general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization.  heent shows the cranium is normocephalic and atraumatic.  she has dry mucosal membrane.  she now has a right facial droop, which per her daughter is new.  neck veins are not distended.  no carotid bruits visible.  skin:  warm, well perfused.  lungs are clear to auscultation anteriorly.  no wheezes.  cardiac exam:  s1, s2, regular rate.  no significant murmurs.  pmi is nondisplaced.  abdomen:  soft, nondistended.  extremities:  without edema, on limited exam.  neurological exam seems to show only the right facial droop. diagnostic/laboratory data:  ekgs as reviewed above.  her last ecg shows normalization of prior st elevation in the inferior leads with q waves and first-degree av block, pr interval 280 milliseconds.  further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, bun 9, creatinine 0.8, glucose 162, troponin 0.17, inr 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179. chest x-ray, no significant pericardial effusion. impression:  the patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized.  i will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of. recommendations:1.  i think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.2.  morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.3.  would avoid other blood thinners including plavix, integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion. other management as per the medical service.  i have discussed the case with dr. x of the hospitalist service who will be admitting the patient."
+"reason for consultation:  new diagnosis of non-small cell lung cancer. history of present illness:  abcd is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage iv metastatic disease.  we are consulted at this time to discuss further treatment options. abcd and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  eventually this prompted him to present to the emergency room.  a ct scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  at that point, he was transferred to xyz hospital for further evaluation.  on admission on 12/19/08, a ct scan of the chest, abdomen, and pelvis was done for full staging purposes.  the ct scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  this was causing some compression on the inferior aspect of the svc and also some narrowing of the right upper lobe pulmonary artery.  there was an abnormal lymph node noted in the ap window and left hilar region.  there was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  there was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  there were areas of atelectasis particularly in the right base.  there was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  there was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  in the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  all other structures appeared normal.  on 12/22/08, a ct-guided biopsy of the left adrenal mass was performed.  pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  at this point, we have been consulted to discuss further treatment options. on further review, abcd states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  he has not ever had a chronic smoker&#8217;s cough and still does not have a cough.  he has no sputum production or hemoptysis.  he and his wife are very anxious about this diagnosis. past medical history:  he denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems. past surgical history:  he denies having any surgeries. allergies:  no known drug allergies. medications:  at home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  he does take a multivitamin on occasion. social history:  he has about a 30-pack-a-year history of smoking.  he used to drink alcohol heavily and has a history of getting a dui about a year-and-half ago resulting in him having his truck-driving license revoked.  since that time he has worked with printing press.  he is married and has two children, both of whom are grown in their 20s, but are now living at home. family history:  his mother died for alcohol-related complications.  he otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems. review of systems:  general/constitutional:  he has lost about 20 pounds of weight as described above.  he also has a trouble with fatigue.  no lightheadedness or dizziness.  heent:  he denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  he does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  respiratory:  he has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  no cough, congestion, wheezing, hemoptysis, and sputum production.  cvs:  he denies any chest pains, palpitations, pnd, orthopnea, or swelling of his lower extremities.  gi:  he denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  he has been somewhat constipated recently.  gu:  he denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  musculoskeletal:  he denies any new bony aches or pains including back pain, hip pain, and rib pain.  no muscle aches, no joint swelling, and no history of gout.  skin:  no rashes, no bruising, petechia, non-healing wounds, or ulcerations.  he has had no nail or hair changes.  hem:  he denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  endocrine:  he denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  neuro:  he denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination. physical examinationvital signs:  his t-max is 98.8.  his pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.general:  no acute distress, pleasant gentleman who appears stated age.heent:  nc/at.  sclerae anicteric.  conjunctiva clear.  oropharynx is clear without erythema, exudate, or discharge.neck:  supple.  nontender.  no elevated jvp.  no carotid bruits.  no thyromegaly.  no thyroid nodules.  carotids are 2+ and symmetric.back:  spine is straight.  no spinal tenderness.  no cva tenderness.  no presacral edema.chest:  clear to auscultation and percussion bilaterally.  no wheezes, rales, or rhonchi.  normal symmetric chest wall expansion with inspiration.cvs:  regular rate and rhythm.  no murmurs, gallops, or rubs.abdomen:  soft, nontender, nondistended.  no hepatosplenomegaly.  no guarding or rebound.  no masses.  normoactive bowel sounds.extremities:  no cyanosis, clubbing, or edema.  no joint swelling.  full range of motion.skin:  no rashes, wounds, ulcerations, bruises, or petechia.neurologic:  cranial nerves ii through xii are intact.  he has intact sensation to light touch throughout.  he has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  he is alert and oriented x3. laboratory data:  his white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  the differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  chemistry shows sodium 138, potassium 3.8, chloride 104, co2 of 31, bun 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, ast 16, alt 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  his inr is 1.0 with the pt of 11.4 and a ptt of 31.3. imagining data:  mri of the brain on 12/23/08 &#8211; this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  there is no evidence of cerebral metastasis, hemorrhage, or acute infarction. assessment/plan:  abcd is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  at this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  his wife particularly had a very hard time with this prognosis.  they preferred not to know the exact average as to how long someone lives with this disease.  i did offer chemotherapy as a way to treat this disease.  chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  at this point, he has an excellent functional status and i think he would tolerate chemotherapy quite well. in terms of chemotherapy, i talked briefly about the side affects including but not limited to gi upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  i would likely use carboplatin and gemcitabine.  this would be both medications given on day 1 with a dose of gemcitabine on day 8.  this cycle will be repeated after 1-week break so that the cycle lasts 21 days.  the goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication. in terms of staging mr. abcd&#8217;s had all the appropriate staging.  a pet-ct scan could be done, but at this point would not provide much mean full information beyond the ct scans that we have. at this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  he will be ready to be discharged from the hospital once his pain is under better control.  as this is the holiday weekend, i do not have a way of scheduling a followup appointment with them, but i did give he and his wife my card and instructed them to call on monday.  at that point, we will get him in and i will also begin working on making arrangements for his chemotherapy. thank you very much for this interesting consult."
+"problem:  rectal bleeding, positive celiac sprue panel. history:  the patient is a 19-year-old irish-greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  she noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  she has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  she actually has none of these symptoms since starting her gluten-free diet.  she has noted intermittent rectal bleeding with constipation, on the toilet tissue.  she feels remarkably better after starting a gluten-free diet. allergies:  no known drug allergies. operations:  she is status post a tonsillectomy as well as ear tubes. illnesses:  questionable kidney stone. medications:  none. habits:  no tobacco.  no ethanol. social history:  she lives by herself.  she currently works in a dental office. family history:  notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  she has two sisters and one brother.  one sister interestingly has inflammatory arthritis. review of systems:  notable for fever, fatigue, blurred vision, rash and itching; her gi symptoms that were discussed in the hpi are actually resolved in that she started the gluten-free diet.  she also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  please see symptoms summary sheet dated april 18, 2005. physical examination:   general:  she is a well-developed pleasant 19 female.  she has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  she has anicteric sclerae.  pink conjunctivae.  perrla.  ent:  mmm.  neck:  supple.  lungs: clear to auscultation.   heart:  regular rate and rhythm.  abdomen: soft, nondistended and nontender.  good bowel sounds.  rectal:  she has no external hemorrhoids and no probable internal hemorrhoids on exam.  lymph:  no cervical lymphadenopathy.  extremities: no edema.  no rash.  neuro/psych:  orientation, memory, motor and gait are intact. impression/plan:  the patient is a 19-year-old female with what appears to be celiac sprue, that is markedly improved on a gluten-free diet.  i discussed with her and her mother that the gold standard really is a small bowel biopsy, but she would have to go back on her gluten diet to obtain the study.  at this point in time, she does not seem to be quite interested in that as she feels to be markedly better for the first time in many years.  i have given her a handout regarding celiac disease as well as a gluten-free diet and we will go ahead and obtain a small bowel follow through as it seems as if she has had symptoms for many years.  we will check a tsh as well as a cbc to make sure she is not anemic and secondary to the rectal bleeding and a sister with inflammatory arthritis, we will go ahead and check a flexible sigmoidoscopy to make sure there are no signs of inflammatory bowel disease."
+"indication:  syncope. holter monitor summary analysis:  analyzed for approximately 23 hours 57 minutes and artefact noted for approximately 23 seconds.  total beats of 108,489, heart rate minimum of approximately 54 beats per minutes at 7 a.m. and maximum of 106 beats per minute at approximately 4 p.m.  average heart rate is approximately 75 beats per minute, total of 31 to bradycardia, longest being 225 beats at approximately 7 in the morning, minimum rate of 43 beats per minute at approximately 01:40 a.m.  total ventricular events of 64, primarily premature ventricular contraction and supraventricular events total beats of 9 atrial premature contractions.  no significant st elevation noted and st depression noted only in one channel for approximately three minutes for a maximum of 2.7 mm. impression of the findings:  predominant sinus rhythm with occasional premature ventricular contraction, occasional atrial premature contractions and mobitz type 1 wenckebach, several episodes, mobitz type ii, 3 to 2 av conduction disease noted as well approximately two episodes and one episode of atrial bigeminy noted.  no significant pauses noted."
+"preoperative diagnosis:  prior history of polyps. postoperative diagnosis:  small polyps, no evidence of residual or recurrent polyp in the cecum. premedications:  versed 5 mg, demerol 100 mg iv. reported procedure:  the rectal chamber revealed no external lesions.  prostate was normal in size and consistency. the colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum.  the position of the scope within the cecum was verified by identification of the ileocecal valve.  navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed. the cecum was extensively studied and no lesion was seen.  there was not even a scar representing the prior polyp.  i was able to see the area across from the ileocecal valve exactly where the polyp was two years ago, and i saw no lesion at all.  the scope was then slowly withdrawn.  in the mid transverse colon, was a small submucosal lesion, which appeared to be a lipoma.  it was freely mobile and very small with normal overlying mucosa.  there was a similar lesion in the descending colon.  both of these appeared to be lipomatous, so no attempt was made to remove them.  there were diverticula present in the sigmoid colon.  in addition, there were two polyps in the sigmoid colon both of which were resected using electrocautery.  there was no bleeding.  the scope was then withdrawn.  the rectum was normal.  when the scope was retroflexed in the rectum, two very small polyps were noted just at the anorectal margin, and so these were obliterated using the electrocautery snare.  there was no specimen and there was no bleeding.  the scope was then straightened, withdrawn, and the procedure terminated. endoscopic impression:1.  small polyps, sigmoid colon, resected them.2.  diverticulosis, sigmoid colon.3.  small rectal polyps, obliterated them.4.  submucosal lesions, consistent with lipomata as described.5.  no evidence of residual or recurrent neoplasm in the cecum."
+"reason for neurological consultation:  muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance. history of present illness:  the patient is a 62-year-old african-american male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two mis, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  he states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  more recently, he describes a burning sensation along with numbness.  this has become a particular problem and of all the problems he has he feels that pain is his primary concern.  over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  he denies any weakness per se, just clumsiness and decreased sensation.  he has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  this has been a fairly longstanding problem, and again has become more prevalent recently.  he does not have any tremor.  he denies any neck pain.  he walks with the aid of a walker because of unsteadiness with gait. recently, he has tried gabapentin, but this was not effective for pain control.  oxycodone helps somewhat and gives him at least three hours pain relief.  because of the pain, he has significant problems with fractured sleep.  he states he has not had a good night&#8217;s sleep in many years.  about six months ago, after an mi and pacemaker insertion, he was transferred to a nursing facility.  at that facility, his insulin was stopped.  since then he has only been on oral medication for his diabetes.  he denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms. past medical history:  diabetes, hypertension, coronary artery disease, stroke, arthritis, gerd, and headaches. medications:  trazodone, simvastatin, hydrochlorothiazide, prevacid, lisinopril, glipizide, and gabapentin. family history:  discussed above and documented on the chart. social history:  discussed above and documented on the chart.  he does not smoke.  he lives in a senior citizens building with daily nursing aids.  he previously was a security guard, but is currently on disability. review of systems:  discussed above and documented on the chart. physical examination:  on examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  pain scale 7/10.  a full general and neurological examination was performed on the patient and is documented on the chart. the patient is obese with significant ankle edema. neurological examination reveals normal cognitive exam and normal cranial nerve examination.  motor examination reveals mild atrophy in bilateral fdis, but still has a strong grip.  individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  tone and bulk are normal.  sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  he has no vibration sense at his knees.  similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  the only reflexes i could obtain with trace reflexes in his biceps.  remaining reflexes were unelicitable.  no babinski.  the patient walks normally with the aid of a cane.  he has severe sensory ataxia with inability to walk unaided.  positive romberg with eyes open and closed. impression and plan:1.  probable painful diabetic neuropathy.  symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  he has relative preservation of motor function.  because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, i would like to rule out other causes of progressive neuropathy.2.  he has history of myoclonic jerks.  i did not see any on my examination today and i feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  i would like to rule out other causes such as hepatic encephalopathy. i have recommended the following:1.  emg/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.2.  blood work, looking for other causes of neuropathy and myoclonus, to include cbc, cmp, tsh, lft, b12, rpr, esr, lyme titer, and hba1c, and ammonia level.3.  neurontin and oxycodone have not been effective, and i have recommended cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  side effect profile of this medication was discussed with the patient.4.  i have explained to him that progression of diabetic neuropathy is closely related to diabetic control and i have recommended tight diabetic control.5.  i will see him at followup at the emg."
+"chief complaint:  headache. hpi:  this is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on ct scan.  he was discharged home with a follow up to neurosurgery on the 14th.  apparently, an mri the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery.  he has had headaches since the 13th and complains now of some worsening of his pain.  he denies photophobia, fever, vomiting, and weakness of the arms or legs. pmh:  as above. meds:  vicodin. allergies:  none. physical exam:  bp 180/110 pulse 65 rr 18 temp 97.5.mr. p is awake and alert, in no apparent distress.heent:  pupils equal, round, reactive to light, oropharynx moist, sclera clear.  neck:  supple, no meningismus.lungs:  clear.heart:  regular rate and rhythm, no murmur, gallop, or rub.  abdomen:  benign.neuro:  awake and alert, motor strength normal, no numbness, normal gait, dtrs normal.  cranial nerves normal.   course in the ed:  patient had a repeat head ct to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus.  i recommended an lp but he prefers not to have this done.  he received morphine for pain and his headache improved.  i&#8217;ve recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram.  he left the ed against my advice.   impression:  headache, improved.  intracranial aneurysm. plan:  the patient will return tomorrow am for his angiogram."
+"preoperative diagnoses:1.  odynophagia.2.  dysphagia.3.  gastroesophageal reflux disease rule out stricture. postoperative diagnoses:1.  antral gastritis.2.  hiatal hernia. procedure performed:  egd with photos and biopsies. gross findings:  this is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  she has a previous history of hiatal hernia.  she was on prevacid currently.  at this time, an egd was performed to rule out stricture.  at the time of egd, there was noted some antral gastritis and hiatal hernia.  there are no strictures, tumors, masses, or varices present. operative procedure:  the patient was taken to the endoscopy suite in the lateral decubitus position.  she was given sedation by the department of anesthesia.  once adequate sedation was reached, the olympus gastroscope was inserted into oropharynx.  with air insufflation entered through the proximal esophagus to the ge junction.  the esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices.  there was a hiatal hernia present.  the scope was passed through the hiatal hernia into the body of the stomach.  in the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions.  multiple biopsies were obtained.  the scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits.  the scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and ge junction.  as stated, multiple biopsies were obtained. the scope was then slowly withdrawn.  the patient tolerated the procedure well and sent to recovery room in satisfactory condition."
+"exam:  chest pa &#038; lateral. reason for exam:  shortness of breath, evaluate for pneumothorax versus left-sided effusion. interpretation:  there has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe.  the lower lobe appears aerated.  there is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation.  the heart and pulmonary vascularity are within normal limits.  left-sided port is seen with groshong tip at the svc/ra junction.  no evidence for acute fracture, malalignment, or dislocation. impression:1.  interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.2.  rest of visualized exam nonacute/stable.3.  left central line appropriately situated and stable.4.  preliminary report was issued at time of dictation.  dr. x was called for results."
+"preoperative diagnosis:  foreign body in airway. postoperative diagnosis:  plastic piece foreign body in the right main stem bronchus. procedure:  rigid bronchoscopy with foreign body removal. indications for procedure:  this patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom.  the patient had a chest x-ray and based on that there is concern by the radiology it could be a foreign body in the right main stem.  the patient has been taken to the operating room for rigid bronchoscopy and foreign body removal. description of procedure:  the patient was taken to the operating room, placed supine, put under general mask anesthesia.  using a 3.5 rigid bronchoscope we visualized between the cords into the trachea.  there were some secretions but that looked okay.  got down at the level of the carina to see a foreign body flapping in the right main stem.  i then used graspers to grasp to try to pull into the scope itself.  i could not do that, i thus had to pull the scope out along with the foreign body that was held on to with a grasper.  it appeared to be consisting of some type of plastic piece that had broke off some different object.  i took the scope and put it back down into the airway again.  again, there was secretion in the trachea that we suctioned out.  we looked down into the right bronchus intermedius.  there was no other pathology noted, just some irritation in the right main stem area.  i looked down the left main stem as well and that looked okay as well.  i then withdrew the scope.  trachea looked fine as well as the cords.  i put the patient back on mask oxygen to wake the patient up.  the patient tolerated the procedure well."
+"history of present illness:  the patient is a 50-year-old african american female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on june 22, 2007.  the patient presents with no complaints for cadaveric renal transplant.  after appropriate cross match and workup of hla typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney. preoperative diagnosis:  endstage renal disease. postoperative diagnosis:  endstage renal disease. procedure:  cadaveric renal transplant to right pelvis. estimated blood loss:  400 ml. fluids:  one liter of normal saline and one liter of 5% of albumin. anesthesia:  general endotracheal. specimen:  none. drain:  none. complications:  none. the patient tolerated the procedure without any complication. procedure in detail:  the patient was brought to the operating room, prepped and draped in sterile fashion.  after adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the asis down to the suprapubic space.  after this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat.  camper&#8217;s and scarpa&#8217;s were dissected with electrocautery.  hemostasis was achieved throughout the tissue plains with electrocautery.  the external oblique aponeurosis was identified with musculature and was entered with electrocautery.  then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia.  additionally, the rectus sheath was entered in a linear fashion.  after these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection.  after the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery.  upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties.  after the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane.  this was done without any complication and without entering the peritoneum grossly.  the round ligament was identified and doubly ligated at this time with #0 silk ties as well.  the dissection continued down now to layer of the alveolar tissue covering the right iliac artery.  this alveolar tissue was cleared using blunt dissection as well as electrocautery.  after the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture.  the right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection.  after the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well.  an additional perforating branch was noted at the inferior pole of the right iliac vein.  this was tied with a #0 silk tie and secured.  hemostasis was achieved at this time and the tie had adequate control.  the dissection continued down and identified all other vital structures in this area.  careful preservation of all vital structures was carried out throughout the dissection.  at this time, satinsky clamp was placed over the right iliac vein.  this was then opened using a #11 blade, approximately 1 cm in length.  the heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked.  the renal vein was then elevated and identified in this area.  a 5-0 double-ended prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 prolene, these were tied down and secured.  the renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles.  the dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 prolene securing both superior and inferior poles.  after such time the 5-0 prolene was run around in a circumferential manner until secured in both superior and inferior poles once again.  after this was done and the artery was secured, the satinsky clamp was removed and a bulldog placed over.  the flow was then opened on the arterial side and then opened on the venous side to allow for proper flow.  the bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney.  the kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow.  at this time, all satinsky clamps were removed and all bulldog clamps were removed.  the dissection then continued down to the layer of the bladder at which time the bladder was identified.  appropriate area on the dome the bladder was identified for entry.  this was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the metzenbaum scissors in a linear fashion.  before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length.  at this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well.  subsequently, the superior and inferior pole stitches with 5-0 prolene were used to secure the ureter to the bladder.  this was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again.  good flow was noted from the ureter at the time of operation.  additional vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself.  at this time, an ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again.  this was inspected and noted for proper control.  irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects.  at this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time.  the kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved.  a 1-0 prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior.  this was secured and knots were dumped.  subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running monocryl.  the patient tolerated procedure well without evidence of complication, transferred to the dunn icu where he was noted to be stable.  dr. a was present and scrubbed through the entire procedure."
+"exam:  ct examination of the abdomen and pelvis with intravenous contrast. indications:  abdominal pain. technique:  ct examination of the abdomen and pelvis was performed after 100 ml of intravenous isovue-300 contrast administration.  oral contrast was not administered.  there was no comparison of studies. findingsct pelvis:within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  there is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  there is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  several smaller fibroids were also suspected. the ovaries are unremarkable in appearance.  there is no free pelvic fluid or adenopathy. ct abdomen:the appendix has normal appearance in the right lower quadrant.  there are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  the small and large bowels are otherwise unremarkable.  the stomach is grossly unremarkable.  there is no abdominal or retroperitoneal adenopathy.  there are no adrenal masses.  the kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  the spleen contains several small calcified granulomas, but no evidence of masses.  it is normal in size.  the lung bases are clear bilaterally.  the osseous structures are unremarkable other than mild facet degenerative changes at l4-l5 and l5-s1. impression:1.  hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.2.  multiple uterine fibroids.3.  prominent endometrium.4.  followup pelvic ultrasound is recommended."
+"indications for procedure:  a 79-year-old filipino woman referred for colonoscopy secondary to heme-positive stools.  procedure done to rule out generalized diverticular change, colitis, and neoplasia. description of procedure:  the patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  informed consent was signed by the patient. with the patient in left decubitus position, had received a cumulative dose of 4 mg of versed and 75 mg of demerol, using olympus video colonoscope under direct visualization was advanced to the cecum.  photodocumentation of appendiceal orifice and the ileocecal valve obtained.  cecum was slightly obscured with stool but the colon itself was adequately prepped.  there was no evidence of overt colitis, telangiectasia, or overt neoplasia.  there was moderately severe diverticular change, which was present throughout the colon and photodocumented.  the rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  the patient tolerated the procedure well without any complications. impression:1.  colonoscopy to the cecum with adequate preparation.2.  long tortuous spastic colon.3.  moderately severe diverticular changes present throughout.4.  mild internal hemorrhoids. recommendations:1.  clear liquid diet today.2.  follow up with primary care physician as scheduled from time to time.3.  increase fiber in diet, strongly consider fiber supplementation."
+"procedure:  left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery. procedure in detail:  the patient was brought to the catheterization laboratory.  after informed consent, he was medicated with versed and fentanyl.  the right groin was prepped and draped, and infiltrated with 2% xylocaine.  percutaneously, #6-french arterial sheath was placed.  selective native left and right coronary angiography was performed followed by left ventricular angiography.  the patient had a totally occluded right coronary.  we initially started with a jr4 guide.  we were able to a sport wire through the total occlusion and saw a very tight stenosis.  we were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  we then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  we then switched to an al1 guide and that too did not enable us to get anything to cross this lesion.  we finally had to go an al2 guide, we were concerned that this could cause some proximal dissection.  that guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  the surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  we then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm vision stent, where the lesion was and post-dilated it to 18 atmospheres.  routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 vision balloon and dilate the area and re-establish flow to the small segment.  we then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm vision stent at 18 atmospheres.  final angiography showed resolution of the dissection.  we could see a little staining extrinsic to the stent.  no perforation and excellent flow.  during the intervention, we did give a bolus and drip of angiomax.  at the end of the procedure, we stopped the angiomax and gave 600 mg of plavix.  we did a right femoral angiogram; however, the angio-seal plug could not take, so we used manual pressure and a femostop.  we transported the patient to his room in stable condition. angiographic data:  left main coronary is normal.  left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the lad before it bifurcates into diagonal.  the diagonal does appear to have about 50% osteal stenosis.  there is a lot of plaquing further down the diagonal, but good flow.  the rest of the lad looked good pass the proximal 60% stenosis and after the diagonal branch.  circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  the first obtuse marginal had a long 50% narrowing and then the av groove branch was free of any disease.  some mild collaterals to the right were seen.  right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  after we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  following the balloon angioplasty, we established good flow down the distal vessel.  we still had about residual 70% stenosis.  when we had to go back with the al2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  we re-dilated and then deployed.  repeat angiography now did show some hang up off dye distally.  we never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  after deploying the stent, we had total resolution of the original lesion.  we then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large pda.  the posterolateral branch appeared to be occluded in its mid portion.  we got a wire through and dilated this.  we then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  there were no filling defects in the stent and excellent flow.  the distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there. impression:  atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch."
+"preoperative diagnosis:  refractory pneumonitis. postoperative diagnosis:  refractory pneumonitis. procedure performed:  bronchoscopy with bronchoalveolar lavage. anesthesia:  5 mg of versed. indications:  a 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis. procedure:  the patient was sedated with 5 mg of versed that was placed on the endotracheal tube.  bronchoscope was advanced.  both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  relatively few tenacious secretions were noted.  these were lavaged out.  specimen collected for culture.  no obvious other abnormalities were noted.  the patient tolerated the procedure well without complication."
+"exam:  ultrasound abdomen. reason for exam:  elevated liver function tests. interpretation:  the liver demonstrates heterogeneously increased echotexture with significant fatty infiltration.  the gallbladder is surgically absent. there is no fluid collection in the cholecystectomy bed.  there is dilatation of the common bile duct up to 1 cm.  there is also dilatation of the pancreatic duct that measures up to 3 mm.  there is caliectasis in the right kidney.  the bladder is significantly distended measuring 937 cc in volume.  the caliectasis in the right kidney may be secondary to back pressure from the distended bladder.  the aorta is normal in caliber. impression:1.  dilated common duct as well as pancreatic duct as described.  given the dilatation of these two ducts, ercp versus mrcp is recommended to exclude obstructing mass.  the findings could reflect changes of cholecystectomy.  2.  significantly distended bladder with probably resultant caliectasis in the right kidney.  clinical correlation recommended."
+"history:  smoking history zero. indication:  dyspnea with walking less than 100 yards. procedure:  fvc was 59%.  fev1 was 61%.  fev1/fvc ratio was 72%. the predicted was 70%.  the fef 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  svc was 69%. inspiratory capacity was 71%.  expiratory residual volume was 61%.  the tgv was 94%.  residual volume was 113% of its predicted.  total lung capacity was 83%.  diffusion capacity was diminished. impression:1.  moderate restrictive lung disease.2.  some reversible small airway obstruction with improvement with bronchodilator.3.  diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.4.  flow volume loop was consistent with the above and no upper airway obstruction."
+"history:  this 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  no confirmed prior history of heart attack, myocardial infarction, heart failure.  history dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  the blood pressure was up transiently last summer when this seemed to start and she was asked not to take claritin-d, which she was taking for what she presumed was allergies.  she never had treated hypertension.  she said the blood pressure came down.  she is obviously very hypertensive this evening.  she has some mid scapular chest discomfort.  she has not had chest pain, however, during any of the other previous symptoms and spells. cardiac risks:  does not smoke, lipids unknown.  again, no blood pressure elevation, and she is not diabetic. family history:  negative for coronary disease.  dad died of lung cancer. drug sensitivities:  penicillin. current medications:  none. surgical history:  cholecystectomy and mastectomy for breast cancer in 1992, no recurrence. systems review:  did not get headaches or blurred vision.  did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  no reflux, abdominal distress.  no other types of indigestion, gi bleed.  gu:  negative.  she is unaware of any kidney disease.  did not have arthritis or gout.  no back pain or surgical joint treatment.  did not have claudication, carotid disease, tia.  all other systems are negative. physical findingsvital signs:  presenting blood pressure was 170/120 and her pulse at that time was 137.  temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  saturation of 86%.  currently, blood pressure 120/70, heart rate is down to 100.eyes:  no icterus or arcus.dental:  good repair.neck:  neck veins, cannot see jvd, at this point, carotids, no bruits, carotid pulse brisk.lungs:  fine and coarse rales, lower two thirds of chest.heart:  diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  there is loud third heart sound.  no murmur.abdomen:  overweight, guess you would say obese, nontender, no liver enlargement, no bruits.skeletal:  no acute joints.extremities:  good pulses.  no edema.neurologically:  no focal weakness.mental status:  clear. diagnostic data:  12-lead ecg, left bundle-branch block. laboratory data:  all pending. radiographic data:  chest x-ray, pulmonary edema, cardiomegaly. impression1.  acute pulmonary edema.2.  physical findings of dilated left ventricle.3.  left bundle-branch block.4.  breast cancer in 1992. plan:  admit.  aggressive heart failure management.  get echo.  start ace and coreg.  diuresis of course underway."
+"history of present illness:  i was kindly asked to see ms. abc who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. the patient is somnolent at this time, but does arouse, but is unable to provide much history.  by review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor.  she states that 1-1/2 hours later she was able to get herself off the floor. the patient denies any chest pain nor clear shortness of breath. past medical history:  includes, end-stage renal disease from hypertension.  she follows up with dr. x in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done.  she had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated pa systolic pressure of 71 mmhg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the pa systolic pressure was estimated at 90 mmhg.  other findings were not significantly changed including pericardial effusion description.  she has a history of longstanding hypertension.  she has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion.  she has a history of hypertension, depression, hyperlipidemia, on sensipar for tertiary hyperparathyroidism. past surgical history:  includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula.  she follows up with dr. y regarding neurovascular surgery. medications:  on admission:1.  norvasc 10 mg once a day.2.  aspirin 81 mg once a day.3.  colace 200 mg two at bedtime.4.  labetalol 100 mg p.o. b.i.d.5.  nephro-vite one tablet p.o. q.a.m.6.  dilantin 100 mg p.o. t.i.d.7.  renagel 1600 mg p.o. t.i.d.8.  sensipar 120 mg p.o. every day.9.  sertraline 100 mg p.o. nightly.10.  zocor 20 mg p.o. nightly. allergies:  to medications per chart are none. family history:  unable to obtain as the patient becomes quite sleepy when i am talking. social history:  unable to obtain as the patient becomes quite sleepy when i am talking. review of systems:  unable to obtain as the patient becomes quite sleepy when i am talking. physical exam:  temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, o2 saturation 98%.  height is 5 feet 1 inch, weight 147 pounds.  on general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted.  heent shows the cranium is normocephalic and atraumatic.  she has moist mucosal membranes.  neck veins are difficult to assess, but do not appear clinically distended.  no carotid bruits.  lungs are clear to auscultation anteriorly.  no wheezes.  cardiac exam:  s1, s2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla.  no rub, no gallop.  pmi is nondisplaced.  abdomen:  soft, nondistended.  cva is benign.  extremities with no significant edema.  pulses appear grossly intact.  she has evidence of right upper extremity edema, which is apparently chronic. diagnostic data/lab data:  ekgs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor r-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change.  the atrial fibrillation appears present since at least on ekg done on 11/02/07 and this ekg is not significantly changed from the most recent one.  echocardiogram results as above.  chest x-ray shows mild pulmonary vascular congestion.  bnp shows 3788.  sodium 136, potassium 4.5, chloride 94, bicarbonate 23, bun 49, creatinine 5.90.  troponin was 0.40 followed by 0.34.  inr 1.03 on 05/18/07.  white blood cell count 9.4, hematocrit 42, platelet count 139. impression:  ms. abc is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time.  she does have chronic atrial fibrillation again documented at least present since 2007 and i found an ekg report by dr. x, which shows atrial fibrillation on 08/29/07 per her report.  one of the questions we were asked was whether the patient would be a candidate for coumadin.  clearly given her history of small mini-strokes, i think coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk.  if not felt to be significant fall risk then i would strongly recommend coumadin as the patient herself states that she has only fallen twice in the past year.  i would defer that decision to dr. z and dr. xy who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate. recommendations:1.  fall assessment as per dr. z and dr. xy with possible pt consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on coumadin.  given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.2.  the patient has elevated bnp and i suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal lv function, i would not make any further evaluation of that other than aggressive diuresis.3.  regarding this minimal troponin elevation, i do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what i can tell and there is no evidence of tamponade.  i would defer to her usual cardiologist dr. x whether an outpatient stress evaluation is appropriate for risk stratification.  i did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal lv function seen on that study as well.4.  continue norvasc for history of hypertension as well as labetalol.5.  the patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary cva, thromboprophylaxis (albeit understanding that it is inferior to coumadin).6.  continue dilantin for history of seizures."
+"preoperative diagnoses:  multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm. postoperative diagnoses:  multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm. title of the operation:1.  biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.2.  insertion of left lateral ventriculostomy under stealth stereotactic guidance.3.  right suboccipital craniectomy and excision of tumor.4.  microtechniques for all the above.5.  stealth stereotactic guidance for all of the above and intraoperative ultrasound. indications:  the patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  a year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  she recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  she had a consult with radiation-oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  consequently, this operation is performed. procedure in detail:  the patient underwent a planning mri scan with stealth protocol.  she was brought to the operating room with fiducial still on her scalp.  general endotracheal anesthesia was obtained.  she was placed on the mayfield head holder and rolled into the prone position.  she was well padded, secured, and so forth.  the neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  the posterior aspect of the calvarium was shaved and prepared in the usual manner with betadine soak scrub followed by betadine paint.  this was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the stealth system.  sterile drapes were applied and the accuracy of the system was confirmed.  a biparietal incision was performed.  a linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  a biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the stealth stereotactic system.  the dura was opened and reflected back to the midline.  an inner hemispheric approach was used to reach the very large metastatic tumor.  this was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  the tumor was wrapped around and included the choroidal vessels.  at least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  complete removal of the tumor was confirmed by intraoperative ultrasound. once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  a linear incision was made just lateral to the greater occipital nerve.  sharp dissection was carried down in the subcutaneous tissues and bovie electrocautery was used to reach the skull.  a burr hole was placed down low using a craniotome.  a craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  it was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  the ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining csf relieving pressure in the posterior fossa.  upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy. at the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  the tumor, as the one above, was removed, both piecemeal and with intraoperative cavitron ultrasonic aspirator.  a gross total excision of this tumor was obtained as well. i then explored underneath the cerebellum in hopes of finding another metastasis in the cp angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter. meticulous hemostasis was obtained for this wound as well. the posterior fossa wound was then closed in layers.  the dura was closed with interrupted and running mattress of 4-0 nurolon.  the dura was watertight, and it was covered with blue glue.  gelfoam was placed over the dural closure.  then, the muscle and fascia were closed in individual layers using #0 ethibond.  subcutaneous was closed with interrupted inverted 2-0 and 0 vicryl, and the skin was closed with running locking 3-0 nylon. for the cranial incision, the ventriculostomy was brought out through a separate stab wound.  the bone flap was brought on to the field.  the dura was closed with running and interrupted 4-0 nurolon.  at the beginning of the case, dural tack-ups had been made and these were still in place.  the sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked gelfoam to take care of any small bleeding areas in the sinuses. once the dura was closed, the bone flap was returned to the wound and held in place with the lorenz microplates.  the wound was then closed in layers.  the galea was closed with multiple sutures of interrupted 2-0 vicryl.  the skin was closed with a running locking 3-0 nylon. estimated blood loss for the case was more than 1 l.  the patient received 2 units of packed red cells during the case as well as more than 1 l of hespan and almost 3 l of crystalloid. nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady."
+"the patient was brought to the endoscopy suite, where they were placed in left lateral sims position and underwent iv sedation.  digital rectal examination was performed, which showed no masses.  the colonoscope was placed in the rectum and advanced under direct vision to the cecum.  the remainder of the colonoscopy was normal.  on withdrawal of the scope, there was no evidence of any mass, lesions, mucosal abnormalities, friability, or polyps.  the patient was then awakened and taken from the endoscopy suite in stable condition."
+"history of present illness:  the patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of cva with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  according to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  in august of 2007, she was treated with doxorubicin and, as well as procrit and her blood pressure started to go up to over 200s.  her lisinopril was increased to 40 mg daily.  she was also given metoprolol and hctz two weeks ago, after she visited the emergency room with increased systolic blood pressure.  denies any physical complaints at the present time.  denies having any renal problems in the past. past medical history:  as above plus history of anemia treated with procrit.  no smoking or alcohol use and lives alone. family history:  unremarkable. present medications:  as above. review of systems:  cardiovascular:  no chest pain.  no palpitations.  pulmonary:  no shortness of breath, cough, or wheezing.  gastrointestinal:  no nausea, vomiting, or diarrhea.  gu:  no nocturia.  denies having gross hematuria.  salt intake is minimal.  neurological:  unremarkable, except for history of old cva. physical examination:  blood pressure today is 182/78.  examination of the head is unremarkable.  neck is supple with no jvd.  lungs are clear.  there is no abdominal bruit.  extremities 1+ edema bilaterally. laboratory data:  urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at hospital.  the creatinine is 0.8.  renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  mra of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis. impression and plan:  accelerated hypertension.  no clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative mra.  i could only blame procrit initiation, as well as possible fluid retention as a cause of the patient&#8217;s accelerated hypertension.  she was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  at this point, i would not pursue a diagnosis of renal artery stenosis.  since she is maxed out on lisinopril and her pulse is 60, i would not increase beta-blocker or ace inhibitor.  i will continue hctz at 24 mg daily.  the patient was also given a sample of tekturna, which would hopefully improve her systolic blood pressure.  the patient was told to be stick with her salt intake.  she will report to me in 10 days with the result of her blood pressure.  she will also repeat an sma7 to rule out possible hyperkalemia due to tekturna."
+"<b>chief complaint:</b>  gi bleed.<br><br><b>history of present illness:</b>  the patient is an 80-year-old white female with history of atrial fibrillation, on coumadin, who presented as outpatient, complaining of increasing fatigue.  cbc revealed microcytic anemia with hemoglobin of 8.9.  stool dark brown, strongly ob positive.  the patient denied any shortness of breath.  no chest pain.  no gi complaints.  the patient was admitted to abcd for further evaluation.<br><br><b>past medical history:  </b>significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.<br><br><b>physical examination:</b><br>general:  the patient is in no acute distress.<br>vital signs:  stable.<br>heent:  benign.<br>neck:  supple.  no adenopathy.<br>lungs:  clear with good air movement.<br>heart:  irregularly regular.  no gallops.<br>abdomen:  positive bowel sounds, soft, and nontender.  no masses or organomegaly.<br>extremities:  1+ lower extremity edema bilaterally.<br><br><b>hospital course: </b> the patient underwent upper endoscopy performed by dr. a, which revealed erosive gastritis.  colonoscopy did reveal diverticulosis as well as polyp, which was resected.  the patient tolerated the procedure well.  she was transfused, and prior to discharge hemoglobin was stable at 10.7.  the patient was without further gi complaints.  coumadin was held during hospital stay and recommendations were given by gi to hold coumadin for an additional three days after discharge then resume.  the patient was discharged with outpatient pmd, gi, and cardiology followup.<br><br><b>discharge diagnoses:</b><br>1.  upper gastrointestinal bleed.<br>2.  anemia.<br>3.  atrial fibrillation.<br>4.  non-insulin-dependent diabetes mellitus.<br>5.  hypertension.<br>6.  hypothyroidism.<br>7.  asthma.<br><br><b>condition upon discharge: </b> stable.<br><br><b>medications: </b> feosol 325 mg daily, multivitamins one daily, protonix 40 mg b.i.d., kcl 20 meq daily, lasix 40 mg b.i.d., atenolol 50 mg daily, synthroid 80 mcg daily, actos 30 mg daily, mevacor 40 mg daily, and lisinopril 20 mg daily.<br><br><b>allergies:</b>  none.<br><br><b>diet: </b> 1800-calorie ada.<br><br><b>activity: </b> as tolerated.<br><br><b>followup: </b> the patient to hold coumadin through weekend.  followup cbc and inr were ordered.  outpatient followup as arranged."
+"<strong>reason for exam: </strong>lower quadrant pain with nausea, vomiting, and diarrhea. <strong>technique: </strong>noncontrast axial ct images of the abdomen and pelvis are obtained. <strong>findings: </strong>please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material. gallstones are seen within the gallbladder lumen. no abnormal pericholecystic fluid is seen. the liver is normal in size and attenuation. the spleen is normal in size and attenuation. a 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas. no pancreatic ductal dilatation is seen. there is no abnormal adjacent stranding. no suspected pancreatitis is seen. the kidneys show no stone formation or hydronephrosis. the large and small bowels are normal in course and caliber. there is no evidence for obstruction. the appendix appears within normal limits. in the pelvis, the urinary bladder is unremarkable. there is a 4.2 cm cystic lesion of the right adnexal region. no free fluid, free air, or lymphadenopathy is detected. there is left basilar atelectasis. <strong>impression:</strong> 1. a 2.2 cm low attenuation lesion is seen at the pancreatic tail. this is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised. additionally, when the patient&#8217;s creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed. alternatively, an mri may be obtained. 2. cholelithiasis. 3. left basilar atelectasis. 4. a 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised."
+"chief complaint: nausea and abdominal pain after eating. gall bladder history: the patient is a 36 year old white female.  patient&#8217;s complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. the patient&#8217;s symptoms have been present for 3 months. complaints are relieved with lying on right side and antacids. prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without cbd obstruction. laboratory studies that are elevated include total bilirubin and elevated wbc. past medical history: no significant past medical problems. past surgical history: diagnostic laparoscopic exam for pelvic pain/adhesions. allergies: no known drug allergies. current medications: no current medications. occupational /social history: marital status: married. patient states smoking history of 1 pack per day. patient quit smoking 1 year ago. admits to no history of using alcohol. states use of no illicit drugs. family medical history: there is no significant, contributory family medical history. ob gyn history: lmp: 5/15/1999. gravida: 1. para: 1.  date of last pap smear: 1/15/1998. review of systems:cardiovascular: denies angina, mi history, dysrhythmias, palpitations, murmur, pedal edema, pnd, orthopnea, tia&#8217;s, stroke, amaurosis fugax.pulmonary: denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, tb exposure or treatment.neurological: patient admits to symptoms of seizures and ataxia.skin: denies scaling, rashes, blisters, photosensitivity. physical examination:appearance: healthy appearing. moderately overweight.heent: normocephalic. eom&#8217;s intact. perrla. oral pharynx without lesions.neck: neck mobile. trachea is midline.lymphatic: no apparent cervical, supraclavicular, axillary or inguinal adenopathy.breast: normal appearing breasts bilaterally, nipples everted.  no nipple discharge, skin changes.chest: normal breath sounds heard bilaterally without rales or rhonchi.  no pleural rubs. no scars.cardiovascular: regular heart rate and rhythm without murmur or gallop.abdominal: bowel sounds are high pitched.extremities: lower extremities are normal in color, touch and temperature. no ischemic changes are noted. range of motion is normal.skin: normal color, temperature, turgor and elasticity; no significant skin lesions. impression diagnosis:    gall bladder disease. abdominal pain. discussion: laparoscopic cholecystectomy handout was given to the patient, reviewed with them and questions answered. the patient has given both verbal and written consent for the procedure. plan: we will proceed with laparoscopic cholecystectomy with intraoperative cholangiogram. medications prescribed:   none. procedures scheduled: laparoscopic cholecystectomy scheduled for 3-15-02 at outpatient surgery center."
+"procedure:  eeg during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  the eeg background is symmetric.  independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  no clinical signs of involuntary movements are noted during synchronous video monitoring.  recording time is 22 minutes and 22 seconds.  there is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  no sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  photic stimulation induced a bilaterally symmetric photic driving response. impression:  eeg during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  the eeg findings are consistent with potentially epileptogenic process.  clinical correlation is warranted."
+"preoperative diagnosis:  left acoustic neuroma. postoperative diagnosis:  left acoustic neuroma. procedure performed:  left retrosigmoid craniotomy and excision of acoustic neuroma. anesthesia:  general. operative findings:  this patient had a 3-cm acoustic neuroma.  the tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  the facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections. procedure in detail:  following induction of adequate general anesthetic, the patient was positioned for surgery.  she was placed in a lateral position and her head was maintained with mayfield pins.  the left periauricular area was shaved, prepped, and draped in the sterile fashion.  transdermal electrodes for continuous facial nerve emg monitoring were placed, and no response was verified.  the proposed incision was injected with 1% xylocaine with epinephrine.  next, t-shaped incision was made approximately 5 cm behind the postauricular crease.  the incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use. incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  bergen retractors were used to maintain exposure.  using a cutting bur with continuous suction and irrigation of craniotomy was performed.  the sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  from these structures approximately 4 x 4 cm, a window of bone was removed.  bone shavings were collected during the dissection and placed in siloxane suspension for later use.  the bone flap was also left at the site for further use.  dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  bone wax was used to occlude air cells lateral to the sigmoid sinus.  there was extensively aerated temporal bone.  at this point, dr. trask entered the case in order to open the dura and expose the tumor.  the cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  the dura was excised from around the porous acusticus extending posteriorly along the bone.  then, using diamond burs, the internal auditory canal was dissected out.  the bone was removed laterally for distance of approximately 8 mm.  there was considerable aeration around the internal auditory canal as well.  the dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  the tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  therefore, dr. trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  with dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  the eighth nerve was identified and transected.  tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  the facial nerve was difficult to identify at the brainstem as well.  it was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  the superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  at this point, plane of dissection was again indistinct.  the tumor had been released from the porous and could be rotated.  the tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  the nerve could be stimulated, but was quite splayed over the anterior face.  further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  however, the cerebellopontine angle portion of the nerve was not usually delineated.  however, the tumor was then thinned using cusa down to fine sheath measuring only about 1 to 2 mm in thickness.  it was released from the brainstem ventrally.  the tumor was then cauterized with bipolar electrocautery.  the facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  overall, the remaining tumor volume would be of small percentage of the original volume.  at this point, dr. trask re-inspected the posterior fossa to ensure complete hemostasis.  the air cells around the internal auditory canal were packed off with muscle and bone wax.  a piece of fascia was then laid over the bone defect.  next, the dura was closed with duragen and duraseal.  the bone flap and bone ***** were then placed in the bone defect.  postauricular musculature was then reapproximated using interrupted 3-0 vicryl sutures.  the skin was also closed using interrupted subdermal 3-0 vicryl sutures.  running 4-0 nylon suture was placed at the skin levels.  sterile mastoid dressing was then placed.  the patient tolerated the procedure well and was transported to the pacu in a stable condition.  all counts were correct at the conclusion of the procedure. estimated blood loss:  100 ml."
+"identifying data:  this is a 26-year-old caucasian male of unknown employment, who has been living with his father. chief complaint and/or reaction to hospitalization:  the patient is unresponsive. history of present illness:  the patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father&#8217;s home.  it is unknown how long the patient has been decompensated after a stay at hospital. past psychiatric history:  inpatient ita stay at hospital one year ago, outpatient at valley cities, but currently not engaged in treatment. medical history:  due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height.  he is likely dehydrated, as it appears that he has not had food or fluids for quite some time. current medications:  prior to admission, we do not have that information.  he has been started on ativan 2 mg p.o. or im if he refuses the p.o. and this would be t.i.d. to treat the catatonia. social and developmental history:  the patient has been living in his father&#8217;s home and this is all the information that we have available from the chart. substance and alcohol history:  it is unknown with the exception of nicotine use. legal history:  unknown. genetic psychiatric history:  unknown. mental status exam:attitude:  the patient is unresponsive.appearance:  he is lying in bed in the fetal position with a blanket over his head.psychomotor:  catatonic.eps/td:  unable to assess though his limbs are quite contracted.affect:  unresponsive.mood:  unresponsive.speech:  unresponsive.thought process and thought content:  unresponsive.psychosis:  unable to elicit information to make this assessment.suicidal/homicidal:  also unable to elicit this information.cognitive assessment:  unable to elicit.judgment and insight:  unable to elicit.assets:  the patient is young.limitations:  severe decompensation. formulation:  this is a 26-year-old caucasian male with a diagnosis of psychosis, nos, admitted with catatonia. diagnoses:axis i:  psychosis, nos.axis ii:  deferred.axis iii:  dehydration.axis iv:  severe.axis v:  10. estimated length of stay:  10 to 14 days. recommendations and plan:1.  stabilize medically from the dehydration per internal medicine.2.  medications, milieu therapy to assist with re-compensation.3.  msw for discharge planning.4.  gather more data including information from hospital."
+"cc: falling to left. hx: 26y/orhf fell and struck her head on the ice 3.5 weeks prior to presentation. there was no associated loss of consciousness. she noted a dull headache and severe sharp pain behind her left ear 8 days ago. the pain lasted 1-2 minutes in duration. the next morning she experienced difficulty walking and consistently fell to the left. in addition the left side of her face had become numb and she began choking on food. family noted her pupils had become unequal in size. she was seen locally and felt to be depressed and admitted to a psychiatric facility. she was subsequently transferred to uihc following evaluation by a local ophthalmologist. meds: prozac and ativan (both recently started at the psychiatric facility). pmh: 1) right esotropia and hyperopia since age 1year. 2) recurrent uti. fhx: unremarkable. shx: divorced. lives with children. no spontaneous abortions. denied etoh/tobacco/illicit drug use. exam: bp 138/110.  hr 85.  rr 16.  temp 37.2c. ms: a&#038;o to person, place, time. speech fluent and without dysarthria. intact naming, comprehension, repetition. cn: pupils 4/2 decreasing to 3/1 on exposure to light. optic disks flat. vfftc. esotropia od, otherwise eom full. horizontal nystagmus on leftward gaze. decreased corneal reflex, os. decreased pp/temp sensation on left side of face. light touch testing normal. decreased gag response on left. uvula deviates to right. the rest of the cn exam was unremarkable. motor: 5/5 strength throughout with normal muscle bulk and tone. sensory: decreased pp and temp on right side of body. prop/vib intact. coord: difficulty with fnf/hks/ram on left. normal on right side. station: no pronator drift. romberg test not noted. gait: unsteady with tendency to fall to left. reflexes: 3/3 throughout bue and patellae. 2+/2+ achilles. plantar responses were flexor, bilaterally. gen exam: obese. in no acute distress. otherwise unremarkable. heent: no carotid/vertebral/cranial bruits. course: pt/ptt, gs, cbc, tsh, ft4 and cholesterol screen were all within normal limits. hct on admission was negative. mri brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. the patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at c2 and extending to and involving the basilar artery. there is severe, irregular narrowing of the horizontal portion above the posterior arch of c1. the findings were felt consistent with a left vertebral artery dissection. neuro-opthalmology confirmed a left horner&#8217;s pupil by clinical exam and history. cookie swallow study was unremarkable. the patient was placed on heparin then converted to coumadin. the pt on discharge was 17. she remained on coumadin for 3 months and then was switched to asa for 1 year. an otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. a prosthesis was made and no surgical invention was done."
+"subjective:  the patient returns to the pulmonary medicine clinic for followup evaluation of copd and emphysema.  she was last seen in the clinic in march 2004.  since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility.  she is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.at the present time, respiratory status is relatively stable.  she is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit.  she does have occasional cough and a small amount of sputum production.  no fever or chills.  no chest pains. current medications:  the patient"
+"i had the pleasure of seeing the patient in the transplant clinic today.  as you know, he is a 41-year-ole black male who was diagnosed with end-stage renal disease secondary to hypertension.  he has been on hemodialysis since 02/2008.  he is in my clinic for evaluation for cadaver kidney transplantation. past medical/surgical history:  briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on advair and albuterol.  he was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  his past surgical history is only significant for left av fistula on the wrist done in 04/2008.  he still has urine output.  he has no history of blood transfusion. personal and social history:  he is a nonsmoker.  he denies any alcohol.  no illicit drugs.  he used to work as the custodian at the nursing home, but now on disability since 03/2008.  he is married with 2 sons, ages 5 and 17 years old. family history:  no similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  his father is 67 years old, currently alive with asthma.  he also has one sister who has hypertension.  the rest of the 6 siblings are alive and well. allergies:  no known drug allergies. medications:  singulair 10 mg once daily, cardizem 365 mg once daily, coreg 25 mg once daily, hydralazine 100 mg three times a day, lanoxin 0.125 mg once daily, crestor 10 mg once daily, lisinopril 10 mg once daily, phoslo 3 tablets with meals, and advair 250 mg inhaler b.i.d. review of systems:  significant only for asthma.  no history of chest pain normal mi.  he has hypertension.  he occasionally will develop colds especially with weather changes.  gi:  negative.  gu:  still making urine about 1-3 times per day.  musculoskeletal:  negative.  skin:  he complains of dry skin.  neurologic:  negative.  psychiatry:  negative.  endocrine:  negative.  hematology:  negative. physical examination:  a pleasant 41-year-old african-american male who stands 5 feet 6 inches and weighs about 193 pounds.  heent:  anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  chest:  equal chest expansion.  clear breath sounds.  heart:  distinct heart sounds, regular rhythm with no murmur.  abdomen:  soft, nontender, flabby, no organomegaly.  extremities:  poor peripheral pulses.  no cyanosis and no edema. assessment and plan:  this is a 49-year old african-american male who was diagnosed with end-stage renal disease secondary to hypertension.  he is on hemodialysis since 02/2008.  overall, i think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  other than that, i think that he is a reasonable candidate for transplant. i would like to thank you for allowing me to participate in the care of your patient.  please feel free to contact me if there are any questions regarding his case."
+"preoperative diagnosis:  acute appendicitis. postoperative diagnosis:  acute appendicitis, gangrenous. procedure:  appendectomy. description of procedure:  the patient was taken to the operating room under urgent conditions.  after having obtained an informed consent, he was placed in the operating room and under anesthesia.  followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  antibiotics had been given prior to incision.  a mcburney incision was performed and it carried out through the peritoneal cavity.  immediately there was  purulent material seen in the area.  samples were taken for culture and sensitivity of aerobic and anaerobic sets.  the appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  there was quite a bit of local peritonitis.  the mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of vicryl and then a z stitch.  the area was abundantly irrigated with normal saline and also the pelvis.  the distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology. then the peritoneal and internal fascia were approximated with a suture of 0 vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  the skin was closed with a combination of a subcuticular suture of fine monocryl followed by the application of dermabond.  the patient tolerated the procedure well.  estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition."
+"history of present illness:  this is a followup for this 69-year-old african american gentleman with stage iv chronic kidney disease secondary to polycystic kidney disease.  his creatinine has ranged between 4 and 4.5 over the past 6 months, since i have been following him.  i have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes.  on his last visit, i really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control.  he has also brought a machine at home, and states his blood pressure readings have been better.  he has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these i have discussed with him in the past.  he also needs followup for his elevated psa in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant. review of systems:  really negative.  he continues to feel well.  he denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good. current medications:1.  vytorin 10/40 mg one a day.2.  rocaltrol 0.25 micrograms a day.3.  carvedilol 12.5 mg twice a day.4.  cozaar 50 mg twice a day.5.  lasix 40 mg a day. physical examination:vital signs:  on exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings.  general:  he is a thin african american gentleman in no distress.  lungs:  clear.  cardiovascular:  regular rate and rhythm.  normal s1 and s2.  i did not appreciate a murmur.  abdomen:  soft.  he has a very soft systolic murmur at the left lower sternal border.  no rubs or gallops.  extremities:  no significant edema. laboratory data:  today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact pth 458, and hemoglobin stable at 10.9.  he is not on epo yet.  his ua has been negative. impression:1.  chronic kidney disease, stage iv, secondary to polycystic kidney disease.  his estimated gfr is 16 ml per minute.  he has no uremic symptoms.2.  hypertension, which is finally better controlled.3.  metabolic bone disease.4.  anemia. recommendation:  he needs a number of things done in terms of followup and education.  i gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes.  i also gave him websites that he can get on to find out more information.  i have not made any changes in his medications.  he is getting blood work done prior to his next visit with me.  i will check a psa on him but he needs to get back into see urology, as his last psa that i see was 37 and this was from 02/05.  he will see me back in about 4 to 6 weeks."
+"discharge disposition:  the patient was discharged by court as a voluntary drop by prosecution.  this was ama against hospital advice. discharge diagnoses:axis i:  schizoaffective disorder, bipolar type.axis ii:  deferred.axis iii:  hepatitis c.axis iv:  severe.axis v:  19. condition of patient on discharge:  the patient remained disorganized.  the patient was suffering from prolactinemia secondary to medications. discharge followup:  to be arranged per the patient as the patient was discharged by court. discharge medications:  a 2-week supply of the following was phoned into the patient&#8217;s pharmacy:  seroquel 25 mg p.o. nightly.  zyprexa 5 mg p.o. b.i.d. mental status at the time of discharge:  attitude was cooperative.  appearance showed fair hygiene and grooming.  psychomotor behavior showed restlessness.  no eps or td was noted.  affect was restricted.  mood remained anxious and speech was pressured.  thoughts remained tangential, and the patient endorsed paranoid delusions.  the patient denied auditory hallucinations.  the patient denied suicidal or homicidal ideation, was oriented to person and place.  overall, insight into her illness remained impaired. history and hospital course:  the patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  the patient reportedly was asking her father to have sex with her and tried to pull down her mother&#8217;s pants.  the patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  the patient has a history of depression versus bipolar disorder, last hospitalized in pierce county in 2008, but without recent treatment.  the patient on admission interview was noted to be labile and disorganized.  the patient was initiated on risperdal m-tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by rebecca richardson, md.  the patient remained labile and suspicious during her hospital stay.  the patient continued to be sexually preoccupied and had poor insight into her need for treatment.  the patient denied further auditory hallucinations.  the patient was treated with seroquel for persistent mood lability and psychosis.  the patient was noted to develop prolactinemia with risperdal and this was changed to zyprexa prior to discharge.  the patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  the patient was discharged to return home to her parents and was referred to community mental health agencies.  the patient was thus discharged in symptomatic condition."
+"precatheterization diagnosis (es): hypoplastic left heart, status post norwood procedure and glenn shunt. postcatheterization diagnosis (es):1. hypoplastic left heart.a. status post norwood.b. status post glenn.2. left pulmonary artery hypoplasia.3. diminished right ventricular systolic function.4. trivial neo-aortic stenosis.5. trivial coarctation.6. flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch. procedure (s): right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein. i. procedures: xxxxxx was brought to the catheterization lab and was anesthetized by anesthesia. he was intubated. his supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. the patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. xylocaine was administered in the right femoral area. a 6-french sheath was introduced into the right femoral vein percutaneously without complication. a 4-french sheath was introduced into the right femoral artery percutaneously without complication. a 4-french pigtail catheter was introduced and passed to the abdominal aorta. dr. hayes, using the siterite device, introduced a 5-french sheath into the right internal jugular vein without complication. a 5-french wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. this catheter would not pass to the right pulmonary artery. the wedge catheter was removed. a 5-french ima catheter was then introduced and passed to the right pulmonary artery. after right pulmonary artery pressure was measured, this catheter was removed. the 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: inferior vena cava, right atrium, left atrium, and right ventricle. the previously introduced 4 pigtail catheter was advanced to the ascending aorta. simultaneous right ventricular and ascending aortic pressures were measured. a pullback from ascending aorta to descending aorta was then performed. simultaneous measurements of right ventricular and descending aortic pressures were measured. the wedge catheter was removed. a 5-french berman catheter was advanced down the glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to glenn shunt was performed. an injection was then performed using omnipaque 16 ml at 8 ml per second with the berman catheter positioned in the glenn shunt. the 5-french berman was removed. a 6-french berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. a right ventriculogram was performed using omnipaque 18 ml at 12 ml per second. the berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using omnipaque 10 ml at 8 ml per second. the 4-french pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using omnipaque 16 ml at 12 ml per second. following the ascending angiograms, two kidneys and a bladder were noted. the catheters and sheaths were removed, and hemostasis was obtained by direct pressure. the estimated blood loss was less than 30 ml, and none was replaced. heparin was administered following placement of all of the sheaths. pulse oximetry saturation, pulse in the right foot, and ekg were monitored continuously. ii. pressures:a. left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, a6 to 9, v6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7. b. ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10. c. pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to glenn, mean of 12 to mean of 13; right pulmonary artery to glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35. interpretation: right and left pulmonary artery pressures are appropriate for this situation. there is a gradient of, at most, 2 mmhg on pullback from both the right and left pulmonary arteries to the glenn shunt. the left atrial mean pressure is normal. right ventricular end-diastolic pressure is, at most, slightly elevated. there is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. there is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. on pullback from ascending to descending aorta, there is a 6-mmhg gradient between the two. systemic blood pressure is normal. iii. oximetry: superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83. interpretation: systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. the saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient. iv. special procedure (s): none done. v. calculations:please see the calculation sheet. calculations were based upon an assumed oxygen consumption. the _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. using the above information, the pulmonary to systemic flow ratio was 0.6. systemic blood flow was 5.1 liters per minute per meter squared. pulmonary blood flow was 3.2 liters per minute per meter squared. systemic resistance was 9.8 wood&#8217;s units times meter squared, which is mildly diminished. pulmonary resistance was 2.5 wood&#8217;s units times meter squared, which is in the normal range. vi. angiography: the injection to the glenn shunt demonstrates a wide-open glenn connection. the right pulmonary artery is widely patent, without stenosis. the proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. the right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. the aorta at the diaphragm on a later injection was 5.5 mm. there is a small collateral off the innominate vein passing to the left upper lobe. flow to both upper lobes is diminished versus lower lung fields. there is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. there is normal return of the left lower pulmonary vein and left upper pulmonary vein. there is some reflux of dye into the inferior vena cava from the right atrium. the right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. the calculated ejection fraction from the lao projection is only mildly diminished at 59%. there is no significant tricuspid regurgitation. the neo-aortic valve appears to open well with no stenosis. the ascending aorta is dilated. there is mild narrowing of the aorta at the isthmal area. on some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient&#8217;s style of norwood reconstruction. there is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right. the inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium. the ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. the coronary arteries are poorly seen. again, a portion of the aorta appears to be partially duplicated. there is faint opacification of the left upper lung from collateral blood flow. the above-mentioned narrowing of the aortic arch is again noted."
+"preoperative diagnosis:  abdominal wall abscess. postoperative diagnosis:  abdominal wall abscess. procedure:  incision and drainage (i&#038;d) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body. anesthesia:  lma. indications:  patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  came in approximately 36 hours ago with pain across his lower abdomen.  ct scan demonstrated presence of an abscess beneath the incision.  i recommended to the patient he undergo the above-named procedure.  procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery. findings:  the patient was found to have an abscess that went down to the level of the fascia.  the anterior layer of the fascia was fibrinous and some portions necrotic.  this was excisionally debrided using the bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well. technique:  patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with betadine solution and draped in a sterile fashion.  the wound opening where it was draining was explored using a curette.  the extent of the wound marked with a marking pen and using the bovie cautery, the abscess was opened and drained.  i then noted that there was a significant amount of undermining.  these margins were marked with a marking pen, excised with bovie cautery; the curette was used to remove the necrotic fascia.  the wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  a dressing was applied.  the finished wound size was 9.0 x 5.3 x 5.2 cm in size.  patient tolerated the procedure well.  dressing was applied, and he was taken to recovery room in stable condition."
+"eeg during wakefulness demonstrates background activity consisting of beta rhythms in the 12- to 14-hz range.  some ekg artifact is noted intermittently.  the background activity appears to be bilaterally symmetric and consistent throughout.  the recording time is 22 minutes and 57 seconds.  there is some attenuation of the background activity during drowsiness.  some late sleep is recorded.  photic stimulation induced no abnormal changes in the record.  no paroxysmal or focal abnormalities are seen in this recording. impression:  eeg during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity."
+"history of present illness:  this 40-year-old white single man was hospitalized at xyz hospital in the mental health ward, issues were filled up by his sister and his mother.  the issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother.  he has been in outpatient therapy with jeffrey silverberg for the past 10 years and mr. silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office. the history includes the fact that the patient is the 3rd of 4 children.  a brother who is approximately 8 years older, sexually abused brother who is 4 years older.  the brother who is 8 years older lives in california and will contact the family, has had minimal contact for many years. that brother in california is gay.  the brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis.  he said, he told his mother several years ago, but she did nothing about it. the patient finished high school and with some struggle completed college at the university of houston.  he has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion.  she has been concerned about patient&#8217;s behavior and was instrumental in having him committed. reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened. he had no or minimal psychiatric treatment growing up and after completing college worked in retail part time. he states he injured his back about 10 yeas ago.  he told he had disk problems but never had surgery.  he subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself. he has been on a variety of different medications including celexa 40 mg and add medication different times, and reportedly has used amphetamines in the past, although he denies it at this time.  he minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed. he has never been psychiatrically hospitalized before. mental status examination:  revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family&#8217;s commitment.  he says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother&#8217;s wife what had happened.  the brother has a child and wife became very upset with him. normocephalic.  pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded.  his affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times. recent past memory were intact. diagnoses:axis i:  major depression rule out substance abuse.axis ii:  deferred at this time.axis iii:  noncontributory.axis iv:  family financial and social pressures.axis v:  global assessment of functioning 40. recommendation:  the patient will be hospitalized to assess. along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree.  he says he has had several part time jobs, but never been able to sustain employment, although he would like to."
+"admitting diagnosis:  intractable migraine with aura. discharge diagnosis:  migraine with aura. secondary diagnoses:1.  bipolar disorder.2.  iron deficiency anemia.3.  anxiety disorder.4.  history of tubal ligation. procedures during this hospitalization:1.  ct of the head with and without contrast, which was negative.2.  an mra of the head and neck with and without contrast also negative.3.  the cta of the neck also read as negative.4.  the patient also underwent a lumbar puncture in the emergency department, which was grossly unremarkable though an opening pressure was not obtained. home medications:1.  vicodin 5/500 p.r.n.2.  celexa 40 mg daily.3.  phenergan 25 mg p.o. p.r.n.4.  abilify 10 mg p.o. daily.5.  klonopin 0.5 mg p.o. b.i.d.6.  tramadol 30 mg p.r.n.7.  ranitidine 150 mg p.o. b.i.d. allergies:  sulfa drugs. history of present illness:  the patient is a 25-year-old right-handed caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the july 31, 2008.  she described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  the patient also perceived some swelling in her face.  once in the emergency department, the patient underwent a very thorough evaluation and examination.  she was given the migraine cocktail.  also was given morphine a total of 8 mg while in the emergency department.  for full details on the history of present illness, please see the previous history and physical. brief summary of hospital course:  the patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  the patient was brought up to 4 or more early in the a.m. on the august 1, 2008 and was given the dihydroergotamine iv, which did allow some minimal resolution in her headache immediately.  at the time of examination this morning, the patient was feeling better and desired going home.  she states the headache had for the most part resolved though she continues to have some diffuse trigger point pain. physical examination at the time of discharge:  general physical exam was unremarkable.  heent:  pupils were equal and respond to light and accommodation bilaterally.  extraocular movements were intact.  visual fields were intact to confrontation.  funduscopic exam revealed no disc pallor or edema.  retinal vasculature appeared normal.  face is symmetric.  facial sensation and strength are intact.  auditory acuities were grossly normal.  palate and uvula elevated symmetrically.  sternocleidomastoid and trapezius muscles are full strength bilaterally.  tongue protrudes in midline.  mental status exam: revealed the patient alert and oriented x 4.  speech was clear and language is normal.  fund of knowledge, memory, and attention are grossly intact.  neurologic exam:  vasomotor system revealed full power throughout.  normal muscle tone and bulk.  no pronator drift was appreciated.  coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  no tremor or dysmetria.  excellent sensory.  sensation is intact in all modalities throughout. the patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  gait was assessed, the patient&#8217;s routine and tandem gait were normal.  the patient is able to balance on heels and toes.  romberg is negative.  reflexes are 2+ and symmetric throughout.  babinski reflexes are plantar. disposition:  the patient is discharged home. instructions for followup:  the patient is to followup with her primary care physician as needed."
+"month dd, yyyy xyz re:  abcmedical record#:  123 dear dr. xyz: i saw abc back in neuro-oncology clinic today.  he comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma. within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  the patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  it is clear that his mri is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time. after seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  they came in with a list of eight possible agents that they would like to be administered within the next two weeks.  they then wanted another mri to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation. from my view, i noticed a man whose language has deteriorated in the week since i last saw him.  this is very worrisome.  today, for the first time, i felt that there was a definite right facial droop as well.  therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  it suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future. emphasizing this once again, in addition, to recommending steroids i once again tried to convince him to undergo radiation.  despite an hour, this again amazingly was not possible.  it is not that he does not want treatment, however.  because i told him that i did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to temodar in a low dose daily type regimen.  we would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  in addition, we will stop thalidomide 100 mg/day.  if he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  at this stage, we are thinking of using accutane at that point. while i am very uncomfortable with this type of approach, i think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  in the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  i will look at this as a positive sign because i think radiation is the one therapy from which he can get a reasonable response in the long term. i will keep you apprised of followups.  if you have any questions or if i could be of any further assistance, feel free to contact me. sincerely,"
+"history of present illness:  this 57-year-old black female was seen in my office on month dd, yyyy for further evaluation and management of hypertension.  patient has severe backache secondary to disc herniation.  patient has seen an orthopedic doctor and is scheduled for surgery.  patient also came to my office for surgical clearance.  patient had cardiac cath approximately four years ago, which was essentially normal.  patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  patient does not use a cpap mask.  her exercise tolerance is eight to ten feet for shortness of breath.  patient also has two-pillow orthopnea.  she has intermittent pedal edema. physical examination:  vital signs:  blood pressure is 135/70.  respirations 18 per minute.  heart rate 70 beats per minute.  weight 258 pounds.heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good. neck:  supple.  jvp is flat.  carotid upstroke is good. lungs:  clear. cardiovascular:  there is no murmur or gallop heard over the precordium. abdomen:  soft.  there is no hepatosplenomegaly. extremities:  the patient has no pedal edema.   medications:  1.  buspar 50 mg daily.2.  diovan 320/12.5 daily.3.  lotrel 10/20 daily.4.  zetia 10 mg daily.5.  ambien 10 mg at bedtime.6.  fosamax 70 mg weekly. diagnoses:1.  controlled hypertension.2.  morbid obesity.3.  osteoarthritis.4.  obstructive sleep apnea syndrome.5.  normal coronary arteriogram.6.  severe backache. plan:1.  echocardiogram, stress test.2  routine blood tests.3.  sleep apnea study.4.  patient will be seen again in my office in two weeks."
+"indication:  bradycardia and dizziness. comments:1.  the patient was monitored for 24 hours.2.  the predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.3.  there were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.4.  there was a frequent premature ventricular contraction seen.  between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  during rest of the monitoring period, there were just occasional premature ventricular contractions seen.  no ventricular tachycardia was seen.5.  there were no pathological pauses noted.6.  the longest rr interval was 1.1 second.7.  there were no symptoms reported."
+"reason for visit:  the patient is a 76-year-old man referred for neurological consultation by dr. x.  the patient is companied to clinic today by his wife and daughter.  he provides a small portion of his history; however, his family provides virtually all of it. history of present illness:  he has trouble with walking and balance, with bladder control, and with thinking and memory.  when i asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  he is vaguely aware that he has trouble with his memory. according to his family, he has had difficulty with his gait for at least three or four years.  at first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  they did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  as time progressed, he developed more and more difficulty.  he started to shuffle.  he started using a cane about two and a half years ago and has used a walker with wheels in the front since july of 2006.  at this point, he frequently if not always has trouble getting in or out of the seat.  he frequently tends to lean backwards or sideways when sitting.  he frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  he has not fallen in the last month.  he did fall earlier, but there seemed to be fewer opportunities for him to fall.  his family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  he has no stairs in his home, however, his family indicates that he would not be able to take stairs.  his handwriting has become smaller and shakier. in regard to the bladder, he states, &quot;i wet the bed.&quot;  in talking with his family, it seems as if he has no warning that he needs to empty his bladder.  he was diagnosed with a small bladder tumor in 2005.  this was treated by dr. y.  dr. x does not think that the bladder tumor has anything to do with the patient&#8217;s urinary incontinence.  the patient has worn a pad or undergarment for at least one to one and a half years.  his wife states that they go through two or three of them per day.  he has been placed on medications; however, they have not helped. he has no headaches or sensation of head fullness. in regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  now he seems less spontaneous and his family states he seems to have trouble expressing himself.  his wife took over his medications about two years ago.  she stopped his driving about three years ago.  she discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  apparently, he did not object.  at this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  he needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  he is a retired office machine repairman.  he is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day. he has not had pt or ot and has not been treated with medications for parkinson&#8217;s disease or alzheimer&#8217;s disease.  he has been treated for the bladder.  he has not had lumbar puncture. past medical history and review of all 14 systems from the form they completed for this visit that i reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  the bladder tumor was discovered in 2005 and was treated noninvasively.  he has lost weight from about 200 pounds to 180 pounds over the last two or three years.  he had a period of depression in 1999 and was on prozac for a while, but this was then stopped.  he used to drink a significant amount of alcohol.  this was problematic enough that his wife was concerned.  she states he stopped when she retired and she was at home all day. social history:  he quit smoking in 1968.  his current weight is 183 pounds.  his tallest height is 5 feet 10 inches. family history:  his grandfather had arthritis.  his father had parkinson&#8217;s disease.  his mother had heart disease and a sister has diabetes. he does not have a living will and indicates he would wish his wife to make decisions for him if he could not make them for himself. review of hydrocephalus risk factors:  none. allergies:  none. medications:  metformin 500 mg three times a day, lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, uroxatral 10 mg per day, detrol la 4 mg per day, and aspirin 81 mg per day. physical exam:  on examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  he is well developed, well nourished, and kempt. vital signs:  his weight is 180 pounds. head:  the head is normocephalic and atraumatic.  the head circumference is 59 cm, which is the 75-90th percentile for an adult man whose height is 178 cm. spine:  the spine is straight and not tender.  i can easily palpate the spinous processes.  there is no scoliosis. skin:  no neurocutaneous stigmata. cardiovascular examination:  no carotid or vertebral bruits. mental status:  assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  the mini-mental state exam score was 17/30.  he did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  there was a tendency for perseveration during the evaluation.  he could not copy the diagram of intersecting pentagons. cranial nerve exam:  no evidence of papilledema.  the pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement. motor exam:  normal bulk and strength, but the tone is marked by significant paratonia.  there is no atrophy, fasciculations, or drift.  there is tremulousness of the outstretched hands. sensory exam:  is difficult to interpret.  either he does not understand the test or he is mostly guessing. cerebellar exam:  is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  there is no dysarthria. reflexes:  trace in the arms, 2+ at the knees, and 0 at the ankles.  it is not certain whether there is a babinski sign or simply withdrawal. gait:  assessed using the tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired. review of x-rays:  i personally reviewed the mri scan of the brain from december 11, 2007 at advanced radiology.  it shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  the 3rd ventricle contour is flat.  the span is enlarged at 12 mm.  the sylvian aqueduct is patent.  there is a pulsation artifact.  the corpus callosum is effaced.  there are extensive t2 signal abnormalities that are confluent in the corona radiata.  there are also scattered t2 abnormalities in the basal ganglia.  there is a suggestion of hippocampal atrophy.  there is also a suggestion of vermian atrophy. assessment:  the patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  his examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  his mri scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease. problems/diagnoses:1.  possible idiopathic normal pressure hydrocephalus (331.5).2.  probable cerebral small-vessel disease (290.40 &#038; 438).3.  gait impairment (781.2).4.  urinary urgency and incontinence (788.33).5.  dementia.6.  hypertension.7.  hypercholesterolemia.8.  diabetes. plan:  i had a long conversation with him and his family.  i explained how the symptoms raise the question of hydrocephalus, but are not specific.  i also explained how the appearance of the ventricles on the mri scan raise the question of hydrocephalus, but are not specific for.  i also described the evidence on the mri scan of the long-term effects of his vascular risk factors and explained to his family that these can cause a clinical syndrome that is virtually identical to hydrocephalus.  i explained that it is possible for patients to have both and the best way to determine whether he has hydrocephalus, and more specifically whether he would benefit from shunt surgery is to undertake a test with temporary removal of spinal fluid.  i reviewed both our outpatient lumbar puncture approach and our inpatient spinal catheter protocol.  i gave them a printed description of the inpatient spinal catheter protocol.  his daughter tape-recorded our discussions, so that they can review this. we did review the specific risk of 2% to 3% chance of infection associated with the spinal catheter protocol.  i told them that this is not an emergency and they can take the time to review the details and to contact our office if they have any questions, or if they would like to proceed with testing."
+"history:  neurologic consultation was requested to assess and assist with her seizure medication.  the patient is a 3-year 3 months old girl with refractory epilepsy.  she had been previously followed by xyz, but has been under the care of the ucsf epilepsy program and recently by dr. y.  i reviewed her pertinent previous neurology evaluations at chcc and also interviewed mom. the patient had seizure breakthrough in august 2007, which requires inpatient admission, thanksgiving and then after that time had seizures every other day, up-to-date early december.  she remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with diastat.  she presented to our er today with prolonged convulsive seizure despite receiving 20 mg of diastat at home.  mom documented 103 temperature at home.  in the er, this was 101 to 102 degrees fahrenheit.  i reviewed the er notes.  at 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  ucsf fellow was contacted.  she was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  vital weight was 27.  seizures apparently had stopped.  the valproic acid level obtained at 0835 hours was 79.  according to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  other labs slightly showed leukocytosis with white blood cell count 21,000 and normal cmp. previous workup here showed an eeg on 2005, which showed a left posterior focus.  mri on june 2007 and january 2005 were within normal limits.  mom describes the following seizure types:1.  eye blinking with unresponsiveness.2.  staring off to one side.3.  focal motor activity in one arm and recently generalized tonic seizure. she also said that she was supposed to see dr. y this friday, but had postponed it to some subsequent time when results of genetic testing would be available.  she was being to physicians&#8217; care as dr. z had previously being following her last ucsf. she had failed most of the first and second line anti-epileptic drugs.  these include keppra, lamictal, trileptal, phenytoin and phenobarbital.  these are elicited to allergies, but she has not had any true allergic reactions to these.  actually, it has resulted in an allergic reaction resulting in rash and hypotension. she also had been treated with clobazam.  her best control is with her current regimen of valproic acid and tranxene.  other attempts to taper topamax, but this resulted increased seizures.  she also has oligohidrosis during this summertime. current medications:  include diastat 20 mg; topamax 25 mg b.i.d., which is 3.3 per kilo per day; tranxene 15 mg b.i.d.; depakote 125 mg t.i.d., which is 25 per kilo per day. physical examination:vital signs:  weight 15 kg.general:  the patient was awake, she appeared sedated and postictal.neck:  supple.neurological:  she had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed. she was able to follow commands such as when i request that she gave mom a kiss.  she acknowledged her doll.  left fundus is sharp.  she resisted the rest of the exam.  there was no obvious lateralized findings. assessment:  status epilepticus resolved.  triggered by a febrile illness, possibly viral.  refractory remote symptomatic partial epilepsy. impression:  i discussed the maximizing depakote to mom and she concurred.  i recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  for today, she did give an iv depacon 250 mg and the above dosage can be continued iv until she is taking p.o.  dr. x agreed with the changes and orders were written for this.  she can continue her current doses of topamax and tranxene.  this can be given by ng if needed.  topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  i will be available as needed during the rest of her hospitalization.  mom will call contact dr. y an update him about the recent changes."
+"procedure performed:  dddr permanent pacemaker. indication:  tachybrady syndrome. procedure:  after all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  the patient was taken to the cardiac catheterization suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  once adequate anesthesia had been obtained, a thin-walled #18-gauze argon needle was used to cannulate the left subclavian vein.  a steel guidewire was inserted through the needle into the vascular lumen without resistance.  the needle was then removed over the guidewire and the guidewire was secured to the field.  a second #18 gauze argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  a #11-knife blade was used to make a deeper incision.  hemostasis was made complete.  the edges of the incision were grasped and retracted.  using metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  the guidewires were then pulled through the pacemaker pocket.  one guidewire was secured to the field. a bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  the guidewire and dilator were then removed.  next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  the pacemaker lead was then placed in the appropriate position in the right ventricle.  pacing and sensing thresholds were obtained.  the lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  pacing and sensing threshold were then reconfirmed.  next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  the guidewire and dilator were then removed.  under fluoroscopic guidance, the atrial lead was passed into the right atrium.  the sheath was then turned away in standard fashion.  using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  pacing and sensing thresholds were obtained.  the lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  sensing and pacing thresholds were then reconfirmed.  the leads were wiped free of blood and placed into the pacemaker generator.  the pacemaker generator leads were then placed into pocket with the leads posteriorly.  the deep tissues were closed utilizing #2-0 chromic suture in an interrupted stitch fashion.  a #4-0 undyed vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  steri-strips overlaid.  a sterile gauge dressing was placed over the site.  the patient tolerated the procedure well and was transferred to the cardiac catheterization room in stable and satisfactory condition. pacemaker data (generator data):manufacturer:  medtronics.model:  sigma.model #:  sdr203b.serial #:  123456789. lead information:right atrial lead:manufacturer:  medtronics.model #:  4568.serial #:  123456789. ventricular lead:manufacturer:  medtronics.model #:  509252.serial #:  123456789. pacing and sensing thresholds:right atrial bipolar lead:  pulse width 0.50 milliseconds, impedance 518 ohms, p-wave sensing 2.2 millivolts, polarity is bipolar. ventricular bipolar lead:  pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, r-wave sensing 9.7 millivolts, polarity is bipolar. parameter settings:  pacing mode dddr:  mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds. impression:  successful implantation of dddr permanent pacemaker. plan:1.  the patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.2.  the patient will be placed on antibiotics for five days to avoid pacemaker infection."
+"history of present illness:  the patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  i asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  he first mentioned that he has neck pain.  he states that he has had this for at least 15 years.  it is worse with movement.  it has progressed very slowly over the course of 15 years.  it is localized to the base of his neck and is sharp in quality.  he also endorses a history of gait instability.  this has been present for a few years and has been slightly progressively worsening.  he describes that he feels unsteady on his feet and &quot;walks like a duck.&quot;  he has fallen about three or four times over the past year and a half. he also describes that he has numbness in his feet.  when i asked him to describe this in more detail, the numbness is actually restricted to his toes.  left is slightly more affected than the right.  he denies any tingling or paresthesias.  he also described that he is slowly losing control of his hands.  he thinks that he is dropping objects due to weakness or incoordination in his hands.  this has also been occurring for the past one to two years.  he has noticed that buttoning his clothes is more difficult for him.  he also does not have any numbness or tingling in the hands.  he does have a history of chronic low back pain. at the end of the visit, when i asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  he did not even mention this on the initial part of my history taking.  when i asked him to describe this further, he states that he experiences a general exhaustion.  he basically lays in bed all day everyday.  i asked him if he was depressed, he states that he is treated for depression.  he is unsure if this is optimally treated.  as i just mentioned, he stays in bed almost all day long and does not engage in any social activities.  he does not think that he is necessarily sad.  his appetite is good.  he has never undergone any psychotherapy for depression. when i took his history, i noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  i asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at johns hopkins a couple of years ago.  he states that the results were normal and that specifically he did not have any dementia. when i asked him when he was first evaluated for his current symptoms, he states that he saw dr. x several years ago.  he believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  he told me that more recently he was evaluated by you after dr. y referred him for this evaluation.  he also saw dr. z for neurosurgical consultation a couple of weeks ago.  he reports that she did not think there was any surgical indication in his neck or back at this point in time. past medical history:  he has had diabetes for five years.  he also has had hypercholesterolemia.  he has had crohn&#8217;s disease for 25 or 30 years.  he has had a colostomy for four years.  he has arthritis, which is reportedly related to the crohn&#8217;s disease.  he has hypertension and coronary artery disease and is status post stent placement.  he has depression.  he had a kidney stone removed about 25 years ago. current medications:  he takes actos, ambien, baby aspirin, coreg, entocort, folic acid, flomax, iron, lexapro 20 mg q.h.s., lipitor, pentasa, plavix, protonix, toprol, celebrex and zetia. allergies:  he states that imuran caused him to develop tachycardia. social history:  he previously worked with pipeline work, but has been on disability for five years.  he is unsure which symptoms led him to go on disability.  he has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  he denies alcohol or illicit drug use.  he lives with his wife.  he does not really have any hobbies. family history:  his father died of a cerebral hemorrhage at age 49.  his mother died in her 70s from complications of congestive heart failure.  he has one sister who died during a cardiac surgery two years ago.  he has another sister with diabetes.  he has one daughter with hypercholesterolemia.  he is unaware of any family members with neurological disorders. review of systems:  he has dyspnea on exertion.  he states that he was evaluated by a pulmonologist and had a normal evaluation.  he has occasional night sweats.  his hearing is poor.  he occasionally develops bloody stools, which he attributes to his crohn&#8217;s disease.  he also was diagnosed with sleep apnea.  he does not wear his cpap machine on a regular basis.  he has a history of anemia.  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&#8217;s visit. physical examination:vital signs:  blood pressure 160/86 hr 100 rr 16 wt 211 pounds pain 3/10general appearance:  he is well appearing in no acute distress.  he has somewhat of a flat affect.cardiovascular:  he has a regular rhythm without murmurs, gallops, or rubs.  there are no carotid bruits.chest:  the lungs are clear to auscultation bilaterally.skin:  there are no rashes or lesions.musculoskeletal:  he has no joint deformities or scoliosis. neurological examination:mental status:  his speech is fluent without dysarthria or aphasia.  he is alert and oriented to name, place, and date.  attention, concentration, and fund of knowledge are intact.  he has 3/3 object registration and 1/3 recall in 5 minutes. cranial nerves:  pupils are equal, round, and reactive to light and accommodation.  visual fields are full.  optic discs are normal.  extraocular movements are intact without nystagmus.  facial sensation is normal.  there is no facial, jaw, palate, or tongue weakness.  hearing is grossly intact.  shoulder shrug is full. motor:  he has normal muscle bulk and tone.  there is no atrophy.  he has few fasciculations in his calf muscles bilaterally.  manual muscle testing reveals mrc grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  there is no action or percussion myotonia or paramyotonia. sensory:  he has absent vibratory sensation at the left toe.  this is diminished at the right toe.  joint position sense is intact.  there is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  pinprick is intact.  romberg is absent.  there is no spinal sensory level. coordination:  this is intact by finger-nose-finger or heel-to-shin testing.  he does have a slight tremor of the head and outstretched arms. deep tendon reflexes:  they are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  plantar reflexes are flexor.  there is no ankle clonus, finger flexors, or hoffman&#8217;s signs.  he has crossed adductors bilaterally. gait and stance:  he has a slightly wide-based gait.  he has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  he has difficulty with toe raises on the left. radiologic data:  mri of the cervical spine, 09/30/08:  chronic spondylosis at c5-c6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  spondylosis of c6-c7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression. thoracic mri spine without contrast:  minor degenerative changes without stenosis. i do not have the mri of the lumbar spine available to review. laboratory data:  10/07/08:  vitamin b1 210 (87-280), vitamin b6 6, esr 6, ast 25, alt 17, vitamin b12 905, cpk 226 (0-200), t4 0.85, tsh 3.94, magnesium 1.7, rpr nonreactive, crp 4, lyme antibody negative, spep abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin a1c 6.0, aldolase 3.9 and homocystine 9.0. assessment:  the patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  his neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  he has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks. i think that the etiology of his symptoms is multifactorial.  he probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  he really is most concerned about the fatigue and i think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  whether he has another underlying muscular disorder such as a primary myopathy remains to be seen. recommendations:1.  i scheduled him for repeat emg and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.2.  i will review his films at our spine conference tomorrow although i am confident in dr. z&#8217;s opinion that there is no surgical indication.3.  i gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.4.  i believe that he needs to undergo psychotherapy for his depression.  it may also be worthwhile to adjust his medications, but i will defer to his primary care physician for managing this or for referring him to a therapist.  the patient is very open about proceeding with this suggestion.5.  he does need to have his sleep apnea better controlled.  he states that he is not compliant because the face mask that he uses does not fit him well.  this should also be addressed.6.  i also am checking another cpk to see if there is any elevation."
+"this is a middle-aged male with increasing memory loss and history of lyme disease. findings:there is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. this mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x ap x mediolateral) in size.   the lesion extends into the left cavernous sinus along the inferior edge of the c3 segment of the left cavernous carotid artery obscuring the left cranial nerves iii, iv and vi. the v1 and v2 branches however can be identified. there is intense enhancement of this lesion following gadolinium augmentation. there is a focal central area of nonenhancement which measures approximately 4mm in diameter. there is right-sided deviation of the infundibulum with mild convex bowing of this mass lesion into the suprasellar cistern, however, there is no impingement upon the optic chiasm. there is pressure erosion of the floor of the sella turcica bulging into the sphenoid sinus without a demonstrated cortical destruction or invasion of the sphenoid sinus. the lesion most likely represents a macroadenoma. the intense enhancement of the central area of hypointense signal raises the possibility a calcification suggesting a differential diagnosis of a late onset craniopharyngioma. the lesion is not considered consistent with a meningioma. ct imaging would be of benefit for exclusion of calcification. normal flow within the carotid and vertebrobasilar circulation and there is no demonstrated aneurysm of the circle of willis. normal cerebral hemispheres and normal cortical gray matter and white matter tracks. there are no white matter hyperintensities. there is normal enhancement of the dural sinuses and cortical veins. there is no enhancing intraaxial or extraaxial mass lesion. normal basal ganglia and thalami. normal internal and external capsules. normal midbrain, pons and medulla and a normal brainstem cervical cord junction. normal vermis and cerebellar hemispheres. normal calvarium. there is a 1.5cm retention cyst of the posterior wall of the left maxillary antrum. the paranasal sinuses are normal. normal temporal bones. normal central skull base. normal clivus and craniovertebral junction. impression:large intrasellar mass lesion with probable invasion of the left cavernous sinus. see above for size, morphology and pattern of enhancement. differential considerations include a macroadenoma of the pituitary gland versus a craniopharyngioma. ct imaging is recommended for assessment of possible calcifications. retention cyst of the left maxillary antrum. normal supratentorial brainstem and posterior fossa."
+"<strong>exam: </strong>ct abdomen without contrast and pelvis without contrast, reconstruction. <strong>reason for exam: </strong>right lower quadrant pain, rule out appendicitis. <strong>technique: </strong>noncontrast ct abdomen and pelvis. an intravenous line could not be obtained for the use of intravenous contrast material. <strong>findings: </strong>the appendix is normal. there is a moderate amount of stool throughout the colon. there is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. examination of the extreme lung bases appear clear, no pleural effusions. the visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. there is a small hiatal hernia. there is no intrarenal stone or evidence of obstruction bilaterally. there is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. this can be correlated with a followup ultrasound if necessary. the gallbladder has been resected. there is no abdominal free fluid or pathologic adenopathy. there is abdominal atherosclerosis without evidence of an aneurysm. dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. there are surgical clips present. there is a tiny airdrop within the bladder. if this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. <strong>impression:</strong> 1.normal appendix. 2.moderate stool throughout the colon. 3.no intrarenal stones. 4.tiny airdrop within the bladder. if this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. the report was faxed upon dictation."
+"preoperative diagnoses:  dysphagia and esophageal spasm. postoperative diagnoses:  esophagitis and esophageal stricture. procedure:  gastroscopy. medications:  mac. description of procedure:  the olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum.  the hypopharynx was normal and the upper esophageal sphincter was unremarkable.  the esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors.  at this point, there were several linear erosions and a sense of stricturing at 38 cm.  below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors.  the mucosa within the hernia was normal.  the gastric lumen was normal with normal mucosa throughout.  the pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion.  during withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia.  it was decided to attempt dilation of the strictured area, so an 18-mm tts balloon was placed across the stricture and inflated to the recommended diameter.  when the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one.  no stretching of the mucosa took place.  the balloon was deflated and the scope was withdrawn.  the patient tolerated the procedure well and was sent to the recovery room. final diagnoses:1.  esophagitis.2.  minor stricture at the gastroesophageal junction.3.  hiatal hernia.4.  otherwise normal upper endoscopy to the transverse duodenum. recommendations:  continue proton pump inhibitor therapy."
+"procedure note:  pacemaker icd interrogation. history of present illness:  the patient is a 67-year-old gentleman who was admitted to the hospital.  he has had icd pacemaker implantation.  this is a st. jude medical model current drrs, 2207-36 pacemaker. diagnosis:  severe nonischemic cardiomyopathy with prior ventricular tachycardia. findings:  the patient is a ddd mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, r sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  the defibrillator portion is set at vt1 at 139 beats per minute with svt discrimination on therapy is monitor only.  vt2 detection criteria is 169 beats per minute with svt discrimination on therapy of atp times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  vf detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  the patient is in normal sinus rhythm. impression:  normally functioning pacemaker icd post implant day number 1."
+"procedure:  colonoscopy. indications:  hematochezia, personal history of colonic polyps. medications:  midazolam 2 mg iv, fentanyl 100 mcg iv procedure:  a history and physical has been performed, and patient medication allergies have been reviewed.  the patient&#8217;s tolerance of previous anesthesia has been reviewed.  the risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  all questions were answered and informed consent was obtained.  mental status examination:  alert and oriented.  airway examination:  normal oropharyngeal airway and neck mobility.  respiratory examination:  clear to auscultation.  cv examination:  rrr, no murmurs, no s3 or s4.  asa grade assessment:  p1 a normal healthy patient.  after reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  the anesthesia plan was to use conscious sedation.  immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  the heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  the physical status of the patient was re-assessed after the procedure.  after i obtained informed consent, the scope was passed under direct vision.  throughout the procedure, the patient&#8217;s blood pressure, pulse, and oxygen saturations were monitored continuously.  the colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice &#038; ic valve.  the quality of the prep was good.  the patient tolerated the procedure well. findings:1.  a sessile, non-bleeding polyp was found in the rectum.  the polyp was 5 mm in size.  polypectomy was performed with a saline injection-lift technique using the snare.  resection and retrieval were complete.  estimated blood loss was minimal.2.  one pedunculated, non-bleeding polyp was found in the sigmoid colon.  the polyp was 7 mm in size.  polypectomy was performed with a hot forceps.  resection and retrieval were complete.  estimated blood loss was minimal.3.  multiple large-mouthed diverticula were found in the descending colon.4.  internal, non-bleeding, prolapsed with spontaneous reduction (grade ii) hemorrhoids were found on retroflexion. impression:1.  one 5 mm benign appearing polyp in the rectum.  resected and retrieved.2.  one 7 mm polyp in the sigmoid colon.  resected and retrieved.3.  diverticulosis.4.  internal hemorrhoids were found. recommendation:1.  high fiber diet.2.  await pathology results.3.  repeat colonoscopy for surveillance in 3 years.4.  the findings and recommendations were discussed with the patient. cpt code(s):45385, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snaretechnique.45384, 59, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hotbiopsy forceps or bipolar cautery.45381, 59, colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance. icd9 code(s):211.4, benign neoplasm of rectum and anal canal.211.3, benign neoplasm of colon.562.10, diverticulosis of colon (without mention of hemorrhage).455.2, internal hemorrhoids with other complication578.1, blood in stool.v12.72, personal history of colonic polyps."
+"preoperative diagnoses1.  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."
+a 51-year-old male with chest pain and history of coronary artery disease. comparison: none. medications: lopressor 5mg iv at 0920 hours. heart rate: recorded heart rate 55 to 57bpm. exam:initial unenhanced axial ct imaging of the heart was obtained with ecg gating for the purpose of coronary artery calcium scoring (agatston method) and calcium volume determination. 18 gauge iv intracath was inserted into the right antecubital vein. a 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access. multi-detector ct imaging was performed with a 64 slice mdct scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding. 95 cc of isovue was administered followed by a 90cc saline
+"reason for consultation:  followup of seizures. history of present illness:  this is a 47-year-old african-american female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in august of 2002.  at that time, she had one generalized tonic-clonic seizure.  apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  she said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  she had two eegs at that time, one on august 04, 2002 and second on november 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  she also had an mri done on september 05, 2002, with and without contrast that was negative.  her diagnosis was confirmed by dr. x at johns hopkins hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  she was initially started on trileptal, but had some problems with the medication subsequently keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  she reports no seizures in the past several years.  she currently is without complaint. in terms of seizure risk factors she denies head trauma, history of cns infection, history of cva, childhood seizures, febrile seizures.  there is no family history of seizures. past medical history:  significant only for hypertension and left temporal lobe epilepsy. family history:  remarkable only for hypertension in her father.  her mother died in a motor vehicle accident. social history:  she works running a day care at home.  she has three children.  she is married.  she does not smoke, use alcohol or illicit drugs. review of systems:  please see note in chart.  only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications. current medications:  lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide. allergies:  flagyl and aspirin. physical examination:  blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.general examination:  please see note in chart, which is essentially unremarkable except mild obesity. neurological examination:  again, please see note in chart.  mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  there is no drift and there are no abnormalities to orbit.  sensory examination, light touch, and temperature intact at all distal extremities.  cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap. she rises easily from the chair.  she has normal step, stride, arm swing, toe, heel, and tandem.  deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles. she was seen in the emergency room for chest pain one month ago.  ct of the head was performed, which i reviewed, dated september 07, 2006.  the findings were within the range of normal variation.  there is no evidence of bleeding, mass, lesions, or any evidence of atrophy. impression:  this is a pleasant 47-year-old african-american female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine. plan:1.  continue lamotrigine 150 mg p.o. b.i.d.2.  i discussed with the patient the option of a trial of medications.  we need to repeat her eeg as well as her mri prior to weaning her medications.  the patient wants to continue her lamotrigine at this time.  i concur.3.  the patient will be following up with me in six months."
+"<strong>admission diagnoses:</strong> 1. pneumonia, failed outpatient treatment. 2. hypoxia. 3. rheumatoid arthritis. <strong>discharge diagnoses:</strong> 1. atypical pneumonia, suspected viral. 2. hypoxia. 3. rheumatoid arthritis. 4. suspected mild stress-induced adrenal insufficiency. <strong>hospital course: </strong> this very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. she was seen on multiple occasions at urgent care and in her physician&#8217;s office. initial x-ray showed some mild diffuse patchy infiltrates. she was first started on avelox, but had a reaction, switched to augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g rocephin and started on azithromycin. her o2 saturations drifted downward. they were less than 88% when active; at rest, varied between 88% and 92%. decision was made because of failed outpatient treatment of pneumonia. her medical history is significant for rheumatoid arthritis. she is on 20 mg of methotrexate every week as well as remicade every eight weeks. her last dose of remicade was in the month of june. hospital course was relatively unremarkable. ct scan was performed and no specific focal pathology was seen. dr. x, pulmonologist was consulted. he also was uncertain as to the exact etiology, but viral etiology was most highly suspected. because of her loose stools, c. difficile toxin was ordered, although that is pending at the time of discharge. she was continued on rocephin iv and azithromycin. her fever broke 18 hours prior to discharge, and o2 saturations improved, as did her overall strength and clinical status. she was instructed to finish azithromycin. she has two pills left at home. she is to follow up with dr. x in two to three days. because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. she is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). we will consult her rheumatologist as to whether to continue her methotrexate, which we held this past friday. methotrexate is known on some occasions to cause pneumonitis."
+"procedure:  colonoscopy. preoperative diagnosis:  follow up adenomas. postoperative diagnoses:1.  two colon polyps, removed.2.  small internal hemorrhoids.3.  otherwise normal examination of cecum. medications:  fentanyl 150 mcg and versed 7 mg slow iv push. indications:  this is a 60-year-old white female with a history of adenomas.  she does have irregular bowel habits. findings:  the patient was placed in the left lateral decubitus position and the above medications were administered.  the colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  the colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  there was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one.  there was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2.  there were small internal hemorrhoids.  the remainder of the examination was normal to the cecum.  the patient tolerated the procedure well without complication. impression:1.  two colon polyps, removed.2.  small internal hemorrhoids.3.  otherwise normal examination to cecum. plan:  i will await the results of the colon polyp histology.  the patient was told the importance of daily fiber."
+"admission diagnoses:1.  pneumonia, likely secondary to aspiration.2.  chronic obstructive pulmonary disease (copd) exacerbation.3.  systemic inflammatory response syndrome.4.  hyperglycemia. discharge diagnoses:1.  aspiration pneumonia.2.  aspiration disorder in setting of severe chronic obstructive pulmonary disease.3.  chronic obstructive pulmonary disease (copd) exacerbation.4.  acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.5.  hypercapnia on admission secondary to chronic obstructive pulmonary disease.6.  systemic inflammatory response syndrome secondary to aspiration pneumonia.  no bacteria identified with blood cultures or sputum culture.7.  atrial fibrillation with episodic rapid ventricular rate, now rate control.8.  hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.9.  benign essential hypertension, poorly controlled on admission, now well controlled on discharge.10.  aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.11.  hyperlipidemia.12.  acute renal failure on chronic renal failure on admission, now resolved. history of present illness:  briefly, this is 73-year-old white male with history of multiple hospital admissions for copd exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  the patient received 3 nebulizers at home without much improvement.  he was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to bipap. hospital course:  the patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with iv solu-medrol and bipap support for copd exacerbation.  the patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  the patient subsequently received diltiazem, also received p.o. digoxin.  the patient subsequently responded well as well received iv antibiotics including levaquin and zosyn.  the patient made slow, but steady improvement over the course of his hospitalization.  the patient subsequently was able to be weaned off bipap during the day, but continued bipap at night and will continue with bipap if needed.  the patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing bipap, was simply using supplemental o2 at night and was able to maintain appropriate and satisfactory o2 saturations on one-liter per minute supplemental o2 per nasal cannula.  the patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient&#8217;s severe shortness of breath during meal time.  the patient&#8217;s chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  there was also more pronounced patchy alveolar opacity, which appeared to be, &quot;mass like&quot; in the right suprahilar region.  this subsequently resolved and the patient&#8217;s infiltrate slowly improved over the course of his hospitalization.  on the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  this was compared with an examination performed 3 days prior.  the patient also had minimal bilateral effusions.  the patient will continue with clindamycin for the next 2 weeks after discharge.  home health has been ordered and the case has been discussed in detail with shaun eagan, physician assistant at eureka community health center.  the patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  the patient discharged on the following medications. discharge medications:1.  home oxygen 1 to 2 liters to maintain o2 saturations at 89 to 91% at all times.2.  ativan 1 mg p.o. t.i.d.3.  metformin 1000 mg p.o. b.i.d.4.  glucotrol 5 mg p.o. daily.5.  spiriva 1 puff b.i.d.6.  lantus 25 units subcu q.a.m.7.  cardizem cd 180 mg p.o. q.a.m.8.  advair 250/50 mcg, 1 puff b.i.d.  the patient is instructed to rinse with mouthwash after each use.9.  iron 325 mg p.o. b.i.d.10.  aspirin 325 mg p.o. daily.11.  lipitor 10 mg p.o. bedtime.12.  digoxin 0.25 mg p.o. daily.13.  lisinopril 20 mg p.o. q.a.m.14.  duoneb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 duoneb ampule&#8217;s with one refill.15.  prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  no refills.16.  clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill. the patient&#8217;s aspiration pneumonia was discussed in detail.  he is agreeable to obtaining a chest x-ray pa and lateral after 2 weeks of treatment.  note that this patient did not have community-acquired pneumonia.  his discharge diagnosis is aspiration pneumonia.  the patient will continue with a dysphagia 2 diet with thin liquids after discharge.  the patient discharged with home health.  a dietary and speech therapy evaluation has been ordered.  speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease. total discharge time was greater than 30 minutes."
+"identifying data:  the patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation. chief complaint:  &quot;i am not sure.&quot; the patient has poor insight into hospitalization and need for treatment. history of present illness:  the patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in houston, texas.  according to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  the patient had taken an airplane from houston to seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in seattle.  the patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  the patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold). past psychiatric history:  history of schizophrenia, chronic paranoid.  the patient as noted has been treated in houston but has not had recent treatment or medications. past medical history:  no acute medical problems noted. current medications:  none.  the patient was most recently treated with invega and abilify according to his records. family social history:  the patient resides with his father in houston.  the patient has no known history of substances abuse.  the patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold. family psychiatric history:  need to increase database. mental status examination:attitude:  calm and cooperative.appearance:  shows poor hygiene and grooming.psychomotor:  behavior is within normal limits without agitation or retardation.  no eps or tds noted.affect:  is suspicious.mood:  anxious but cooperative.speech:  shows normal rate and rhythm.thoughts:  disorganizedthought content:  remarkable for paranoia &quot;they want to hurt me.&quot;psychosis:  the patient endorses paranoid delusions as above.  the patient denies auditory hallucinations.suicidal/homicidal ideation:  the patient denies on admission.cognitive assessment:  grossly intact.  the patient is alert and oriented x 3.judgment:  poor, shown by noncompliance with treatment.assets:  include stable physical status.limitations:  include recurrent psychosis. formulation:  the patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment. initial impression:axis i:  schizophrenia, chronic paranoid.axis ii:  none.axis iii:  none.axis iv:  severe.axis v:  10. estimated length of stay:  12 days. plan:  the patient will be restarted on invega and abilify for psychosis.  the patient will also be continued on cogentin for eps.  increased database will be obtained."
+"preoperative diagnosis:  metopic synostosis with trigonocephaly. postoperative diagnosis:  metopic synostosis with trigonocephaly. procedures:  1.  bilateral orbital frontal zygomatic craniotomy (skull base approach).2.  bilateral orbital advancement with (c-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.3.  bilateral forehead reconstruction with autologous graft.4.  advancement of the temporalis muscle bilaterally.5.  barrel-stave osteotomies of the parietal bones. anesthesia:  general. procedure:  after induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  scalp was clipped.  he was prepped with chloraprep.  incision was infiltrated with 0.5% xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner. a bicoronal zigzag incision was made and raney clips used for hemostasis.  subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  these were subgaleal flaps.  bipolar and bovie cautery were used for hemostasis.  the craniectomy was outlined with methylene blue.  the pericranium was incised exposing the bone along the outline of the craniotomy. paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  one was just above the nasion and the other was near the bregma.  also bilateral pterional bur holes were drilled.  there was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes. the dura was separated with a #4 penfield dissector and then the craniotomies were fashioned or cut.  i should say with the midas rex drill using the v5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  great care was taken when removing the bone from the midline.  bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled. the wound was irrigated with bacitracin irrigation. the next step was to perform the orbital osteotomies with careful protection of the orbital contents.  osteotomies were made with the midas rex drill using the v5 bit in the orbital roof bilaterally.  this was a very thick and vertically oriented orbital roof on each side.  midas rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  the osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  bone wax was used for hemostasis.  it was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  so we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  this was done with the midas rex drill using b5 bit.  also, the marked ridge just above the nasion was burred down with the midas rex drill.  the osteotomies were also carried down through the zygoma.  at this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally. dr. x cut the bone grafts from the bone flaps and i fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  this created a shelf for the notched bone graft to lean against basically anteriorly.  the posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly. the left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place. holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for isaac. at this point the undersurface of the temporalis muscle was scored using the bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 vicryl suture.  this helped fill-in the indentation left by the orbital advancement at the temporal region. also, i separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly. at this point, gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure. the wound was then irrigated with bacitracin irrigation.  bleeding had been controlled during the procedure with bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 ml and he received that much in packed cells and he also received a unit of fresh frozen plasma. at this point, the reconstruction looked good.  the advancement was about 1 cm and we were pleased with the results.  the wound was irrigated and then the gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 vicryl interrupted suture and #5-0 mild chromic on the skin.  the patient tolerated procedure well.  no complications.  sponge and needle counts were correct.  again, blood loss was bout 300 to 400 ml and he received 2 units of blood and some fresh frozen plasma."
+"<strong>preoperative diagnoses:</strong> 1. neuromuscular dysphagia. 2. protein-calorie malnutrition. <strong>postoperative diagnoses:</strong> 1. neuromuscular dysphagia. 2. protein-calorie malnutrition. <strong>procedures performed:</strong> 1. esophagogastroduodenoscopy with photo. 2. insertion of a percutaneous endoscopic gastrostomy tube. <strong>anesthesia:</strong> iv sedation and local. <strong>complications: </strong>none. <strong>disposition: </strong>the patient tolerated the procedure well without difficulty. <strong>brief history: </strong>the patient is a 50-year-old african-american male who presented to abcd general hospital on 08/18/2003 secondary to right hemiparesis from a cva. the patient deteriorated with several cvas and had became encephalopathic requiring a ventilator-dependency with respiratory failure. the patient also had neuromuscular dysfunction. after extended period of time, per the patient&#8217;s family request and requested by the icu staff, decision to place a feeding tube was decided and scheduled for today. <strong>intraoperative findings: </strong>the patient was found to have esophagitis as well as gastritis via egd and was placed on prevacid granules. <strong>procedure: </strong>after informed written consent, the risks and benefits of the procedure were explained to the patient and the patient&#8217;s family. first, the egd was to be performed. the olympus endoscope was inserted through the mouth, oropharynx and into the esophagus. esophagitis was noted. the scope was then passed through the esophagus into the stomach. the cardia, fundus, body, and antrum of the stomach were visualized. there was evidence of gastritis. the scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus. next, attention was made to transilluminating the anterior abdominal wall for the peg placement. the skin was then anesthetized with 1% lidocaine. the finder needle was then inserted under direct visualization. the catheter was then grasped via the endoscope and the wire was pulled back up through the patient&#8217;s mouth. the ponsky peg tube was attached to the wire. a skin nick was made with a #11 blade scalpel. the wire was pulled back up through the abdominal wall point and ponsky peg back up through the abdominal wall and inserted into position. the endoscope was then replaced confirming position. photograph was taken. the ponsky peg tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well. we will begin tube feeds later this afternoon."
+"observations:  fev1 is 3.76, 103% predicted.  fvc is 4.98, 110% predicted.  ratio is 75.  fef 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%.  dlco is 35, 121% predicted.  residual volume is 3.04, 139% predicted.  total lung capacity is 8.34, 120% predicted. flow volume loop reviewed. interpretation:  mild restrictive airflow limitation.  clinical correlation is recommended."
+"<strong>procedure performed:</strong> 1. left heart catheterization. 2. bilateral selective coronary angiography. <strong>anesthesia: </strong>1% lidocaine and iv sedation, including fentanyl 25 mcg. <strong>indication: </strong>the patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the p2 and p3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest. it was accompanied by diaphoresis and shortness of breath. the patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain. he underwent adenosine cardiolite, which revealed 2 mm st segment depression in leads ii, iii avf, and v3, v4, and v5. stress images revealed left ventricular dilatations suggestive of multivessel disease. he is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test. <strong>procedure: </strong>after risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing. the patient was taken to the cardiac catheterization laboratory where the procedure was performed. the right inguinal area was sterilely cleansed with a betadine solution and the patient was draped in the usual manner. 1% lidocaine solution was used to anesthetize the right inguinal area. once adequate anesthesia had been obtained, a thin-walled argon needle was used to cannulate the right femoral artery. the guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin. the needle was removed and a pressure was held. a #6 french arterial sheath was advanced over the guidewire without resistance. the dilator and guidewire were removed and the sheath was flushed. a judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire. the guidewire was removed and the catheter was connected to the manifold and flushed. the ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis. the catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter. the catheter was removed over guidewire and a judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire. the guidewire was removed and the catheter was connected to the manifold and flushed. the ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views. this catheter was removed. the sheath was flushed the final time. the patient was taken to the postcatheterization holding area in stable condition. <strong>findings:</strong> <strong>left main coronary artery:</strong> this vessel is seen to be heavily calcified throughout its course. begins as a moderate caliber vessel. there is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery. <strong>left anterior descending coronary artery:</strong> this vessel is heavily calcified in its proximal portion. it is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex. there is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches. there is sequential 80% and 90% stenosis in the mid-portion of the vessel. otherwise, the lad is seen to be diffusely diseased. <strong>left circumflex coronary artery: </strong>this vessel is also calcified in its proximal portion. there is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery. there is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased. <strong>right coronary artery: </strong>this is a large caliber vessel and is the dominant system. there is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch. <strong>impression:</strong> 1. three-vessel coronary artery disease as described above. 2. moderate mitral regurgitation per tee. 3. status post venous vein stripping of the left lower extremity and varicosities in both lower extremities. 4. long-standing history of phlebitis. <strong>plan: </strong>consultation will be obtained with cardiovascular and thoracic surgery for cabg and mitral valve repair versus replacement."
+"preoperative diagnoses:1.  vault prolapse.2.  enterocele. preoperative diagnoses:1.  vault prolapse.2.  enterocele. operations:1.  abdominosacrocolpopexy.2.  enterocele repair.3.  cystoscopy.4.  lysis of adhesions. anesthesia:  general endotracheal. estimated blood loss:  less than 100 ml. specimen:  none. brief history:  the patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  the patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed. the patient already had multiple abdominal scars.  risk of open surgery was little bit higher for the patient.  after discussing the options the patient wanted to proceed a pfannenstiel incision and repair of the sacrocolpopexy.  risks of anesthesia, bleeding, infection, pain, mi, dvt, pe, mesh erogenic exposure, complications with mesh were discussed.  the patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  the patient was told to perform no heavy lifting for 3 months, etc.  the patient was bowel prepped, preoperative antibiotics were given. details of the operation:  the patient was brought to the or, anesthesia was applied.  the patient was placed in dorsal lithotomy position.  the patient was prepped and draped in usual sterile fashion.  a pfannenstiel low abdominal incision was done at the old incision site.  the incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  the muscle was split in the middle and peritoneum was entered using sharp mets.  there was no injury to the bowel upon entry.  there were significant adhesions which were unleashed.  all the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  there was minimal space, everything was packed, bookwalter placed then over the sacral bone.  the middle of the sacral bone was identified.  the right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  the ligament over the sacral or sacral __________ was easily identified, 0 ethibond stitches were placed x3.  a 1 cm x 5 cm mesh was cut out.  this was a prolene soft mesh which was tied at the sacral ligament.  the bladder was clearly off the vault area which was exposed, in the raw surface 0 ethibond stitches were placed x3.  the mesh was attached.  the apex was clearly up enterocele sac was closed using 4-0 vicryl without much difficulty.  the ureter was not involved at all in this process.  the peritoneum was closed over the mesh.  please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  prior to closure antibiotic irrigation was done using ancef solution.  the mesh has been exposed in antibiotic solution prior to the usage. after a through irrigation with l and half of antibiotic solution.  all the solution was removed.  good hemostasis was obtained.  all the packing was removed.  count was correct.  rectus abdominus muscle was brought together using 4-0 vicryl.  the fascia was closed using loop #1 pds in running fascia from both sides and was tied in the middle.  subcutaneous tissue was closed using 4-0 vicryl and the skin was closed using 4-0 monocryl in subcuticular fashion.  cystoscopy was done at the end of the procedure.  please note that the foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  cystoscopy was done and indigo carmine has been given.  there was good efflux of indigo carmine in both of the ureteral opening.  there was no injury to the rectum or the bladder.  the bladder appeared completely normal.  the rectal exam was done at the end of the procedure after the cystoscopy.  after the cysto was done, the scope was withdrawn, foley was placed back.  the patient was brought to recovery in the stable condition."
+"diagnosis on admission:  gastrointestinal bleed. diagnoses on discharge1. gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.2. atherosclerotic cardiovascular disease.3. hypothyroidism. procedure:  colonoscopy. findings:  poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed. hospital course:  the patient was admitted to the emergency room by dr. x. he apparently had an ng tube placed in the emergency room with gastric aspirate revealing no blood.  dr. y miller saw him in consultation and recommended a colonoscopy.  a bowel prep was done.  h&#038;hs were stable.  his most recent h&#038;h was 38.6/13.2 that was this morning.  his h&#038;h at admission was 41/14.3.  the patient had the bowel prep that revealed no significant bleeding.  his vital signs are stable.  he is continuing on his usual medications of imdur, metoprolol, and synthroid.  his plavix is discontinued.  he is given iv protonix.  i am hesitant to use prilosec or protonix because of his history of pancreatitis associated with prilosec. the patient&#8217;s pt/inr was 1.03, ptt 25.8.  chemistry panel was unremarkable.  the patient was given a regular diet after his colonoscopy today.  he tolerated it well and is being discharged home.  he will be followed closely as an outpatient.  he will continue his pepcid 40 mg at night, imdur, synthroid, and metoprolol as prior to admission.  he will hold his plavix for now.  they will call me for further dark stools and will avoid pepto-bismol.  they will follow up in the office on thursday."
+"the patient was placed in left lateral decubitus position and the above medications were administered.  the colonoscope was advanced to the cecum, as identified by the ileocecal valve, appendiceal orifice, and blind pouch.  the colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum.  the remainder of the examination was normal to the cecum.  the patient tolerated the procedure well without complication."
+"procedure:  colonoscopy. preoperative diagnoses:  rectal bleeding and perirectal abscess. postoperative diagnosis:  perianal abscess. medications:  mac. description of procedure:  the olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  the preparation was excellent and all surfaces were well seen.  the mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  there was no evidence of either inflammation or a fistulous opening.  the scope was withdrawn.  a careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o&#8217;clock position).  some purulent material could be expressed through the opening.  there was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  in addition, scars were noted in the perianal area.  the first was a small dimpled scar, 1 cm from the anal verge in the 11 o&#8217;clock position.  the second was a dimpled scar about 5 cm from the anal verge on the left buttock&#8217;s cheek.  there were no other abnormalities noted.  the patient tolerated the procedure well and was sent to the recovery room. final diagnoses:1.  normal colonoscopy to the terminal ileum.2.  opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen. recommendations:1.  continue antibiotics.2.  followup with dr. x.3.  if drainage persists, consider surgical drainage."
+"medications:  plavix, atenolol, lipitor, and folic acid. clinical history:  this is a 41-year-old male patient who comes in with chest pain, had had a previous mi in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan. with the patient at rest, 10.3 mci of cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained. procedure and interpretation:  the patient exercised for a total of 12 minutes on the standard bruce protocol.  the peak workload was 12.8 mets.  the resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  the blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  the test was stopped due to fatigue and leg pain.  ekg at rest showed normal sinus rhythm.  the peak stress ekg did not reveal any ischemic st-t wave abnormalities.  there was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  at peak, there was no chest pain noted.  the test was stopped due to fatigue and left pain.  at peak stress, the patient was injected with 30.3 mci of cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging. myocardial perfusion imaging:1.  the overall quality of the scan was good.2.  there was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.3.  the left ventricular cavity appeared normal in size.4.  gated spect images revealed mild septal hypokinesis and mild apical hypokinesis.  overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest. conclusions:1.  good exercise tolerance.2.  less than adequate cardiac stress.  the patient was on beta-blocker therapy.3.  no ekg evidence of stress induced ischemia.4.  no chest pain with stress.5.  mild ventricular bigeminy with exercise.6.  no diagnostic abnormality on the rest and stress myocardial perfusion imaging.7.  gated spect images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest."
+"procedure performed:  right heart catheterization. indication:  refractory chf to maximum medical therapy. procedure:  after risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient&#8217;s family in detail, informed consent was obtained both verbally and in writing.  the patient was taken to cardiac catheterization suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  once adequate anesthesia has been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right internal jugular vein.  a steel guidewire was then inserted through the needle into the vessel without resistance.  small nick was then made in the skin and the needle was removed.  an #8.5 french venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  the guidewire and dilator were then removed.  the sheath was then flushed.  a swan-ganz catheter was inserted to 20 cm and the balloon was inflated.  under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  hemodynamics were measured along the way.  pulmonary artery saturation was obtained.  the swan was then kept in place for the patient to be transferred to the icu for further medical titration.  the patient tolerated the procedure well.  the patient returned to the cardiac catheterization holding area in stable and satisfactory condition. findings:  body surface area equals 2.04, hemoglobin equals 9.3, o2 is at 2 liters nasal cannula.  pulmonary artery saturation equals 37.8.  pulse oximetry on 2 liters nasal cannula equals 93%.  right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the fick method, cardiac index is 1.6 by the fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22. impression:  exam and swan findings consistent with low perfusion given that the mixed venous o2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance. plan:  given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on primacor.  the patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  at this time, we will transfer the patient to the intensive care unit for titration of the primacor therapy.  we will also increase his lasix to 80 mg iv q.d.  we will increase his amiodarone to 400 mg daily.  we will also continue with his coumadin therapy.  as stated previously, we will discontinue vasodilator therapy starting with the isordil."
+"reason for visit:  this is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  her chief complaint today is shortness of breath. history of present illness:  i last saw her in 09/2008.  since then, she has been admitted to abcd hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  she was found to have a fast heart rate in the atrial fibrillation.  she was also found to be in heart failure and so they diuresed her.  they wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one&#8217;s great surprise.  my plan advent is to control her heart rate.  this has been a bit difficult with her retaining fluid.  we will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  she may need to have a pacemaker placed and her av node ablated if this does not work. she notes the shortness of breath and wheezing at nights.  i think these are manifestations of heart failure.  she has peripheral edema.  she is short of breath when she tries to walk a city block.  i believe she takes her medications as directed, but i am never sure she actually is taking them correctly.  in any case, she did not bring her medications with her today. today, she had an ecg which shows atrial fibrillation with a ventricular response of 117 beats per minute.  there is a nonspecific ivcd.  this is unchanged from her last visit except that her heart rate is faster.  in addition, i reviewed her echocardiogram done at xyz.  her ejection fraction is 50% and she has paradoxical septal motion.  her right ventricular systolic pressure is normal.  there are no significant valvular abnormalities. medications:  1.  fosamax &#8211; 70 mg weekly.2.  lisinopril &#8211; 20 mg daily.3.  metformin &#8211; 850 mg daily.4.  amlodipine &#8211; 5 mg daily.5.  metoprolol &#8211; 150 mg twice daily.6.  warfarin &#8211; 5 mg daily.7.  furosemide &#8211; none.8.  potassium &#8211; none.9.  magnesium oxide &#8211; 200 mg daily. allergies:  denied. major findings:  on my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  she is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when i saw her last visit.  she is breathing 1two times per minute and it is unlabored.  eyelids are normal.  she has vitiligo.  pupils are round and reactive to light.  conjunctivae are clear and sclerae are anicteric.  there is no oral thrush or central cyanosis.  she has marked keloid formation on both sides of her neck, the left being worse than the right.  the jugular venous pressure is elevated.  carotids are brisk are without bruits.  lungs are clear to auscultation and percussion.  the precordium is quiet.  the rhythm is irregularly irregular.  she has a variable first and second heart sounds.  no murmurs today.  abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  she has no clubbing or cyanosis, but does have 1+ peripheral edema.  distal pulses are good.  on neurological examination, her mentation is normal.  her mood and affect are normal.  she is oriented to person, place, and time. assessments:  she has chronic atrial fibrillation and heart failure now. problems diagnoses:  1.  chronic atrial fibrillation, anticoagulated and the plan is rate control.2.  heart failure and she needs more diuretic.3.  high blood pressure controlled.4.  hyperlipidemia.5.  diabetes mellitus type 2.6.  nonspecific intraventricular conduction delay.7.  history of alcohol abuse.8.  osteoporosis.9.  normal left ventricular function. procedures and immunizations:  none today. plans:  i have restarted her lasix at 80 mg daily and i have asked her to return in about 10 days to the heart failure clinic.  there, i would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  if this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her av node ablated. thank you for asking me to participate in her care. medication changes:  see the above."
+"<strong>problems and issues:</strong> 1. headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and motrin for abortive treatment. 2. some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily. <strong>history of present illness: </strong>the patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. i obtained and documented a full history and physical examination. i reviewed the new patient questionnaire, which she completed prior to her arrival today. i also reviewed the results of tests, which she had brought with her. briefly, she is a 60-year-old woman initially from ukraine, who had headaches since age 25. she recalls that in 1996 when her husband died her headaches became more frequent. they were pulsating. she was given papaverine, which was successful in reducing the severity of her symptoms. after six months of taking papaverine, she no longer had any headaches. in 2004, her headaches returned. she also noted that she had &#8220;zig-zag lines&#8221; in her vision. sometimes she would not see things in her peripheral visions. she had photophobia and dizziness, which was mostly lightheadedness. on one occasion she almost had a syncope. again she has started taking russian medications, which did help her. the dizziness and headaches have become more frequent and now occur on average once to twice per week. they last two hours since she takes papaverine, which stops the symptoms within 30 minutes. <strong>past medical history: </strong>her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis. <strong>medications:</strong> her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin d, centrum multivitamin tablets, actos, lorazepam as needed, vytorin, and celexa. <strong>allergies: </strong>she has no known drug allergies. <strong>family history: </strong>there is family history of migraine and diabetes in her siblings. <strong>social history: </strong>she drinks alcohol occasionally. <strong>review of systems: </strong>her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. remainder of her full 14-point review of system was unremarkable. <strong>physical examination:</strong> on examination, the patient was pleasant. she was able to speak english fairly well. her blood pressure was 130/84. heart rate was 80. respiratory rate was 16. her weight was 188 pounds. her pain score was 0/10. her general exam was completely unremarkable. her neurological examination showed subtle weakness in her left arm due to discomfort and pain. she had reduced vibration sensation in her left ankle and to some degree in her right foot. there was no ataxia. she was able to walk normally. reflexes were 2+ throughout. she had had a ct scan with constant, which per dr. x&#8217;s was unremarkable. she reports that she had a brain mri two years ago which was also unremarkable. <strong>impression and plan:</strong> the patient is a delightful 60-year-old chemist from ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. she has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. her diagnosis is consistent with vestibular migraine. i do not see evidence of multiple sclerosis, m����ni����re&#8217;s disease, or benign paroxysmal positional vertigo. i talked to her in detail about the importance of following a migraine diet. i gave her instructions including a list of foods times, which worsen migraine. i reviewed this information for more than half the clinic visit. i would like to start her on amitriptyline at a dose of 10 mg at time. she will take motrin at a dose of 800 mg as needed for her severe headaches. she will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. i encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms."
+"reason for consult:  genetic counseling. history of present illness:  the patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  the patient reports her first polyps noted at the age of 50.  she has had colonoscopies required every five years and every time she has polyps were found.  she reports that of her 11 brothers and sister 7 have had precancerous polyps.  she does have an identical twice who is the one of the 11 who has never had a history of polyps.  she also has history of several malignancies in the family.  her father died of a brain tumor at the age of 81.  there is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  her sister died at the age of 65 breast cancer.  she has two maternal aunts with history of lung cancer both of whom were smoker.  also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  there is no other cancer history. past medical history:  significant for asthma. current medications:  include serevent two puffs daily and nasonex two sprays daily. allergies:  include penicillin.  she is also allergic seafood; crab and mobster. social history:  the patient is married.  she was born and raised in south dakota.  she moved to colorado 37 years ago.  she attended collage at the colorado university.  she is certified public account.  she does not smoke.  she drinks socially. review of systems:  the patient denies any dark stool or blood in her stool.  she has had occasional night sweats and shortness of breath, and cough associated with her asthma.  she also complains of some acid reflux as well as anxiety.  she does report having knee surgery for torn acl on the left knee and has some arthritis in that knee.  the rest of her review of systems is negative. physical exam:vitals:    bp:  110/58.  heart rate:  76.  temp:  98.2.  weight:  79.1 kg.gen:      she is very pleasant female, in no acute distress.heent:    pupils are equal, round, and reactive to light.  sclerae are anicteric.  oropharynx is clear.neck:    supple.  she has no cervical or supraclavicular adenopathy.lungs:    clear to auscultation bilaterally.cv:    regular rate; normal s1, s2, no murmurs.abdomen:    soft.  she has positive bowel sounds.  no hepatosplenomegaly.ext:    no lower extremity edema. assessment/plan:  this is a 61-year-old female with strong family history of colon polyps.  the patient reports that her siblings have been very diligent about their preventing health and no one besides her sister who presented with the advanced breast cancer add anything more than precancerous adenomas.  we will plan on proceeding with testing for adenomatous polyps.  i will see her back in clinic once we get the results.  i appreciate the referral."
+"procedures performed:1.  left heart catheterization.2.  bilateral selective coronary angiography.3.  left ventriculogram was not performed. indication:  non-st elevation mi. procedure:  after risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  the patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  once adequate anesthesia had been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right femoral artery.  a steel guidewire was inserted through the needle into the vascular lumen without resistance.  a small nick was then made in the skin.  the pressure was held.  the needle was removed over the guidewire.  next, a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the left main coronary artery was engaged.  using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  the catheter was then removed over the guidewire. next, a judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to manifold and flushed.  the catheter did slip into the left ventricle.  during the rotation, the lvedp was then measured.  the ostium of the right coronary artery was then engaged.  using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  once adequate study has been performed, the catheter was then removed.  the sheath was lastly flushed for the final time. findings:left main coronary artery:  the left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  there is no evidence of any hemodynamically significant stenosis. left anterior descending artery:  the lad is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent timi-i flow distally.  the distal portion was diffusely diseased.  the proximal portion otherwise shows minor luminal irregularities.  the first diagonal branch demonstrated minor luminal irregularities throughout. circumflex artery:  the circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  there is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  the first obtuse marginal branch demonstrates minor luminal irregularities throughout. right coronary artery:  the rca is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  the dominant coronary artery gives off the posterior descending artery and posterolateral artery.  the left ventricular end-diastolic pressure was approximately 22 mmhg.  it should be noted that during injection of the contrast agent that there was st elevation in the inferior leads, which resolved after the injection was complete. impression:1.  three-vessel coronary artery disease involving a subtotaled left anterior descending artery with timi-i flow distally and 90% circumflex lesion and 90% right coronary artery lesion.2.  mildly elevated left-sided filling pressures. plan:1.  the patient will be transferred to providence hospital today for likely pci of the mid lad lesion with a surgical evaluation for a coronary artery bypass grafting.  these findings and plan were discussed in detail with the patient and the patient&#8217;s family.  the patient is agreeable.2.  the patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ace inhibitor, and statin therapy.  the patient will not be placed on plavix secondary to the possibility for coronary bypass grafting.  in light of the patient&#8217;s history of cranial aneurysmal bleed, the patient will be held off of lovenox and integrilin."
+"history of present illness:  mr. abc is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard bruce with horizontal st depressions and moderate apical ischemia on stress imaging only.  he required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details). the patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal lad with a severe mid-lad lesion of 99%, and a mid-left circumflex lesion of 80% with normal lv function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right pda. i discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, i felt he was best suited for transfer for pci.  i discussed the case with dr. x at medical center who has kindly accepted the patient in transfer. condition on transfer:  stable but guarded.  the patient is pain-free at this time. medications on transfer:1.  aspirin 325 mg once a day.2.  metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.3.  nexium 40 mg once a day.4.  zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  i see that his ldl was 136 on may 3, 2002.5.  plavix 600 mg p.o. x1 which i am giving him tonight. other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, gerd, arthritis disposition:  the patient and his wife have requested and are agreeable with transfer to medical center, and we are enclosing the cd rom of his images."
+"reason for consult: anxiety. chief complaint:  &quot;i felt anxious yesterday.&quot; hpi:  a 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent uti, and obstructive uropathy, admitted to the abcd hospital on february 6, 2007, for lightheadedness, weakness, and shortness of breath.  the patient was consulted by psychiatry for anxiety.  i know this patient from a previous consult.  during this recent admission, the patient has experienced anxiety and had a panic attack yesterday with &quot;syncopal episodes.&quot;  she was given ativan 0.25 mg on a p.r.n. basis with relief after one to two hours.  the patient was seen by abc, md, and def, ph.d.  the laboratories were reviewed and were positive for uti, and anemia is also present.  the tsh level was within normal limits.  she previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety.  a low dose of klonopin was also helpful for sedation. past medical history:  metastatic breast cancer to bone.  the patient also has a history of hypertension, hypothyroidism, recurrent uti secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, port-a-cath placement, and hydronephrosis. past psychiatric history:  the patient has a history of depression and anxiety.  she was taking remeron 15 mg q.h.s., ambien 5 mg q.h.s. on a p.r.n. basis, ativan 0.25 mg every 6 hours on a p.r.n. basis, and klonopin 0.25 mg at night while she was at home. family history:  there is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and alzheimer disease in the family. social history:  the patient is married and lives at home with her husband.  she has a history of smoking one pack per day for 18 years.  the patient quit in 1967.  according to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day. medications:1.  klonopin 0.25 mg p.o. every evening.2.  fluconazole 200 mg p.o. daily.3.  synthroid 125 mcg p.o. everyday.4.  remeron 15 mg p.o. at bedtime.5.  ceftriaxone iv 1 g in 1/2 ns every 24 hours. p.r.n. medications:1.  tylenol 650 mg p.o. every 4 hours.2.  klonopin 0.5 mg p.o. every 8 hours.3.  promethazine 12.5 mg every 4 hours.4.  ambien 5 mg p.o. at bedtime. allergies:no known drug allergies laboratory data:these laboratories were done on february 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, bun 35, creatinine 1.5, glucose 90.  white blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000.  tsh level 0.88.  the urinalysis was positive for uti. mental status examination:general appearance:  the patient is dressed in a hospital gown.  she is lying in bed during the interview.  she is well groomed with good hygiene.motor activity:  no psychomotor retardation or agitation noted.  good eye contact.attitude:  pleasant and cooperative.attention and concentration:  normal.  the patient does not appear to be distracted during the interview.mood:  okay.affect:  mood congruent normal affect.thought process:  logical and goal directed.thought content:  no delusions noted.perception:  did not assess.memory:  not tested.sensorium:  alert.judgment:  good.insight:  good. impression:1.  axis i:  possibly major depression or generalized anxiety disorder.2.  axis ii:  deferred.3.  axis iii:  breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.4.  axis iv:  interpersonal stressors.5.  axis v:  gaf of 65. assessment and plan:this is a 69-year-old female who is known to me from a previous consult.  she has a history of breast cancer with metastases, depression, anxiety, recent uti, obstructive uropathy.  the patient experienced anxiety and had a panic attack yesterday with &quot;syncopal episodes.&quot;  it was relieved by ativan 0.25 mg p.r.n. with relief after one to two hours.  she was seen by abc, md, and def, ph.d.  the laboratories were reviewed and were positive for a uti.  anemia is also present.  tsh is within normal limits.  the patient previously responded well to mirtazapine for depression, decreased appetite, decreased sleep, and anxiety.  a low dose of klonopin was also helpful for sedation.  the patient possibly has major depression and generalized anxiety disorder.  there is also history of breast cancer with metastasis.1.  continue remeron 15 mg p.o. at bedtime and klonopin 0.25 mg p.o. at bedtime.2.  klonopin 0.5 mg p.o. on a p.r.n. basis for panic attacks.3.  supportive psychotherapy. thank you for the consult."
+"preoperative diagnosis:  right chronic subdural hematoma. postoperative diagnosis: right chronic subdural hematoma. type of operation:  right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain. anesthesia:  general endotracheal anesthesia. estimated blood loss:  100 cc. operative procedure:  in preoperative identification, the patient was taken to the operating room and placed in supine position.  following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  table was turned.  the right shoulder roll was placed.  the head was turned to the left and rested on a doughnut.  the scalp was shaved, and then prepped and draped in usual sterile fashion.  incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  the parietal boss incision was opened.  it was about an inch and a half in length.  it was carried down to the skull.  self-retaining retractor was placed.  a bur hole was now fashioned with the perforator.  this was widened with a 2-mm kerrison punch.  the dura was now coagulated with bipolar electrocautery.  it was opened in a cruciate-type fashion.  the dural edges were coagulated back to the bony edges.  there was egress of a large amount of liquid.  under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  a subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  it was secured with a 3-0 nylon suture.  the area was closed with interrupted inverted 2-0 vicryl sutures.  the skin was closed with staples.  sterile dressing was applied.  the patient was subsequently returned back to anesthesia.  he was extubated in the operating room, and transported to pacu in satisfactory condition."
+"procedure performed:1.  right heart catheterization.2.  left heart catheterization.3.  left ventriculogram.4.  aortogram.5.  bilateral selective coronary angiography. anesthesia:  1% lidocaine and iv sedation including versed 1 mg. indication:  the patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  she has had atrial fibrillation and previous episodes of congestive heart failure.  she has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea. procedure:  after the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  the patient was taken to the cardiac catheterization lab where the procedure was performed.  the right inguinal area was thoroughly cleansed with betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  once adequate anesthesia had been attained, a thing wall argon needle was used to cannulate the right femoral vein.  a guidewire was advanced into the lumen of the vein without resistance.  the needle was removed and the guidewire was secured to the sterile field.  the needle was flushed and then used to cannulate the right femoral artery.  a guidewire was advanced through the lumen of the needle without resistance.  a small nick was made in the skin and the needle was removed.  this pressure was held.  a #6 french arterial sheath was advanced over the guidewire without resistance.  the dilator and guidewire were removed.  fio2 sample was obtained and the sheath was flushed.  an #8 french sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  a swan-ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  an angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to a manifold and flushed.  left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  using dual transducers together and the mitral valve radius was estimated.  the balloon was deflated and mixed venous sample was obtained.  hemodynamics were measured.  the catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  the right atrial sample was obtained and was negative for shunt.  the swan-ganz catheter was then removed and a left ventriculogram was performed in the rao projection with a single power injection of non-ionic contrast material.  pullback was then performed which revealed a minimal lv-ao gradient.  since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the lao projection with a single power injection of non-ionic contrast material.  the pigtail catheter was then removed and a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the left main coronary artery was carefully engaged.  using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  this catheter was then removed and a judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  this catheter was removed.  the sheaths were flushed final time.  the patient was taken to the postcatheterization holding area in stable condition. findings:hemodynamics:  right atrial pressure 9 mmhg, right ventricular pressure is 53/14 mmhg, pulmonary artery pressure 62/33 mmhg with a mean of 46 mmhg.  pulmonary capillary wedge pressure is 29 mmhg.  left ventricular end diastolic pressure was 13 mmhg both pre and post left ventriculogram.  cardiac index was 2.4 liters per minute/m2.  cardiac output 4.0 liters per minute.  the mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  the aortic valve area is calculated to be 2.08 cm2. left ventriculogram:  no segmental wall motion abnormalities were noted.  the left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted. aortogram:  there was 2+ to 3+ aortic insufficiency noted.  there was no evidence of aortic aneurysm or dissection. left main coronary artery:  this was a moderate caliber vessel and it is rather long.  it bifurcates into the lad and left circumflex coronary artery.  no angiographically significant stenosis is noted. left anterior descending artery:  the lad begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  it tapers in its mid portion to become small caliber vessel.  luminal irregularities are present, however, no angiographically significant stenosis is noted. left circumflex coronary artery:  the left circumflex coronary artery begins as a moderate caliber vessel.  small obtuse marginal branches are noted and this is the nondominant system.  lumen irregularities are present throughout the circumflex system.  however no angiographically significant stenosis is noted. right coronary artery:  this is the moderate caliber vessel and it is the dominant system.  no angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel. impression:1.  nonobstructive coronary artery disease.2.  severe mitral stenosis.3.  2+ to 3+ mitral regurgitation.4.  2+ to 3+ aortic insufficiency."
+"history:  the patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  he also has vacterl association with hydrocephalus.  as an infant, he underwent placement of a right modified central shunt.  on 05/26/1999, he underwent placement of a bidirectional glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, pda ligation, and placement of a 4 mm left-sided central shunt.  on 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  a repeat catheterization on 09/25/2001 demonstrated elevated glenn pressures and significant collateral vessels for which he underwent embolization.  he then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  blood pressures were found to be 13 mmhg with the pulmonary vascular resistance of 2.6-3.1 wood units.  on 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  a repeat catheterization on 09/07/2006, demonstrated mildly elevated fontan pressures in the context of a widely patent fontan fenestration and intolerance of fontan fenestration occlusion.  the patient then followed conservatively since that time.  the patient is undergoing a repeat evaluation to assess his candidacy for a fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract. procedure:  after sedation and local xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  cardiac catheterization was performed as outlined in the attached continuation sheets.  vascular entry was by percutaneous technique, and the patient was heparinized.  monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures. using a 7-french sheath, a 6-french wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  this catheter was then exchanged for a 5-french vs catheter of a distal wire.  apposition of the right pulmonary artery over, which the wedge catheter was advanced.  the wedge catheter could then be easily advanced across the fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle. using a 5-french sheath, a 5-french pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  the catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  left ventricular pressure was found to be suprasystemic.  a balloon valvoplasty was performed using a ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-french flexor sheath positioned within the right atrium.  there was a disappearance of a mild waist prior to spontaneous tear of the balloon.  the balloon catheter was then removed in its entirety. echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  a final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  further attempts to cross tricuspid valve were thus abandoned.  attention was then directed to a fontan fenestration.  a balloon occlusion then demonstrated minimal increase in fontan pressures from 12 mmhg to 15 mmhg.  with less than 10% fall in calculated cardiac index.  the angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  a 7-french flexor sheath was again advanced cross the fenestration.  a 10-mm amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  once the stable device configuration was confirmed, device was released from the delivery catheter.  hemodynamic assessment and the angiograms were then repeated. flows were calculated by the fick technique using an assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity. angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle. after angiography, two normal-appearing renal collecting systems were visualized.  the catheters and sheaths were removed and topical pressure applied for hemostasis.  the patient was returned to the recovery room in satisfactory condition.  there were no complications. discussion:  oxygen consumption was assumed to be normal.  mixed venous saturation was low due to systemic arterial desaturation.  there was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  the right pulmonary veins were fully saturated.  left pulmonary veins were not entered.  there was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the fontan fenestration.  mean fontan pressures were 12 mmhg with a 1 mmhg fall in mean pressure into the distal left pulmonary artery.  right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an a-wave similar to the normal left ventricular end-diastolic pressure of 11 mmhg.  left ventricular systolic pressure was normal with at most 5 mmhg systolic gradient pressure pull-back to the ascending aorta.  phasic ascending and descending aortic pressures were similar and normal.  the calculated systemic flow was normal.  pulmonary flow was reduced to the qt-qs ratio of 0.7621.  pulmonary vascular resistance was normal at 1 wood units. angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  the left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  there was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  angiogram with injection in the superior vena cava showed patent right bidirectional glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the glenn anastomosis and the fontan anastomosis.  there was symmetric contrast flow to both pulmonary arteries.  a large degree of contrast flowed retrograde into the fontan and shunting into the right atrium across the fenestration.  there is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  the branch pulmonaries appeared mildly hypoplastic.  levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  angiogram with injection in the fontan showed a widely patent anastomosis with the inferior vena cava.  majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries. following the device occlusion of fontan fenestration, the fontan and mean pressure increased to 15 mmhg with a 3 mmhg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  there was an increase in the systemic arterial pressures.  mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  the calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a qt-qs ratio of 0.921.  angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the fontan with no protrusion into the fontan and no residual shunt and no obstruction to a fontan flow.  an ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  a small degree of contrast returned to the heart. initial diagnoses:  1.  pulmonary atresia.2.  vacterl association.3.  persistent sinusoidal right ventricle to the coronary communications.4.  hydrocephalus. prior surgeries and interventions:  1.  systemic to pulmonary shunts.2.  right bidirectional glenn shunt.3.  revision of the central shunt.4.  ligation and division of patent ductus arteriosus.5.  occlusion of venovenous and arterial aortopulmonary collateral vessels.6.  extracardiac fontan with the fenestration. current diagnoses:  1.  favorable fontan hemodynamics.2.  hypertensive right ventricle.3.  aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.4.  patent fontan fenestration. current intervention:  1.  balloon dilation tricuspid valve attempted and failed.2.  occlusion of a fontan fenestration. management:  he will be discussed at combined cardiology/cardiothoracic surgery case conference.  a careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  further cardiologic care will be directed by dr. x."
+"diagnosis at admission:  congestive heart failure (chf) with left pleural effusion. diagnoses at discharge1.  congestive heart failure (chf) with pleural effusion.2.  hypertension.3.  prostate cancer.4.  leukocytosis.5. anemia of chronic disease. hospital course:  the patient was admitted to the emergency room by dr. x. he has diuresed with iv lasix.  he was placed on prinivil, aspirin, oxybutynin, docusate, and klor-con.  chest x-rays were followed.  he did have free flowing fluid in his left chest.  radiology consultation was obtained for thoracentesis.  the patient was seen by dr. y. an echocardiogram was done.  this revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3.  an adenosine sestamibi was done in march 2000, with a small fixed apical defect, but no ischemia.  cardiac enzymes were negative.  dr. y recommended a beta-blocker with an ace inhibitor; therefore, the lisinopril was discontinued.  the patient felt much better after the thoracentesis.  i do not have the details of this, i.e., the volumes.  no fluid was sent for routine studies. laboratory at discharge:  sodium 134, potassium 4.2, chloride 99, co2 26, glucose 182, bun 17, and creatinine 1.0.  glucose was elevated because of several doses of solu-medrol given to him because of bronchospams.  magnesium was 1.8, calcium was 8.1.  liver enzymes were unremarkable.  cardiac enzymes were normal as mentioned.  pt/inr is 1.02, ptt 31.3, white blood cell count 15, 000 with a left shift.  this was presumed due to the corticosteroids.  h&#038;h was 32.3/11.3 and platelets 352,000, and mcv was 99.  the patient&#8217;s o2 saturations on room air were normal. vital signs were stable. discharge medications:  he is being discharged home on lasix 40 mg daily, potassium chloride 10 meq daily, atenolol 25 mg daily, aspirin 5 grains daily, ditropan 5 mg b.i.d., and colace 100 mg b.i.d. followup:  he will be followed in my office in 1 week.  he is to notify if recurrent fever or chills. prognosis:  guarded."
+"preoperative diagnosis:  angina and coronary artery disease. postoperative diagnosis:  angina and coronary artery disease. name of operation:  coronary artery bypass grafting (cabg) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, st. jude proximal anastomosis used for vein graft.  off-pump medtronic technique for left internal mammary artery, and a bivad technique for the circumflex. anesthesia:  general. procedure details:  the patient was brought to the operating room and placed in the supine position upon the table.  after adequate general anesthesia, the patient was prepped with betadine soap and solution in the usual sterile manner.  elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case. a midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  pericardial and thymus fat pad was divided.  the left internal mammary artery was harvested and spatulated for anastomosis.  heparin was given. vein resected from the thigh, side branches secured using 4-0 silk and hemoclips.  the thigh was closed multilayer vicryl and dexon technique.  a pulsavac wash was done, drain was placed. the left internal mammary artery is sewn to the left anterior descending using 7-0 running prolene technique with the medtronic off-pump retractors.  after this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  medtronic retractors used to expose the circumflex.  prior to going on pump, we stapled the vein graft in place to the aorta. then, on pump, we did the distal anastomosis with a 7-0 running prolene technique.  the right side graft was brought to the posterior descending artery using running 7-0 prolene technique.  deairing procedure was carried out.  the bulldogs were removed.  the patient maintained good normal sinus rhythm with good mean perfusion.  the patient was weaned from cardiopulmonary bypass.  the arterial and venous lines were removed and doubly secured.  protamine was delivered.  meticulous hemostasis was present.  platelets were given for coagulopathy.  chest tube was placed and meticulous hemostasis was present.  the anatomy and the flow in the grafts was excellent.  closure was begun. the sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 vicryl sutures in double-layer technique.  the skin was closed with subcuticular 4-0 dexon suture technique.  the patient tolerated the procedure well and was transferred to the intensive care unit in stable condition. we minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0."
+"indications for procedure: the patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. she is here for catheterization. approach: right common femoral artery. anesthesia: iv sedation per cardiac catheterization protocol. local sedation with 1% xylocaine. complications: none. estimated blood loss: less than 10 ml. estimated contrast: less than 150 ml. procedures performed: left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 french angio-seal placement. operative technique: the patient was brought to the cardiac catheterization lab in the usual fasting state. she was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. one percent xylocaine was infiltrated into the right femoral vessels. next, a #6 french sheath was then placed in the right common femoral artery by the modified seldinger technique. selective coronary arteriography: next, right and left judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views. left ventriculogram: next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. next, an lv-gram was then performed with a hand injection of 50 ml of contrast. next, pull-back pressure was measured across the aortic valve. aorta arch angiogram: next, aortic arch angiogram was then performed with injection of 50 ml of contrast at a rate of 20 ml/second to maximum pressure of 750 psi performed in the 40-degree lao view. next, right iliofemoral angiogram was performed in the 20-degree rao view. next angio-seal was applied successfully. the patient left the cath lab without problems or issues. diagnoses: left ventricular end-diastolic pressure was 18 mmhg. there was no gradient across the aortic valve. the central aortic pressure was 160 mmhg. left ventriculogram: the left ventriculogram demonstrated normal lv systolic function with estimated ejection fraction greater than 50%. aortic arch angiogram: the aortic arch angiogram demonstrated normal aortic arch. no aortic regurgitation was seen. selective coronary arteriography: the right coronary artery is large and dominant. the left main is patent. the left anterior descending is patent. the left circumflex is patent. impression: this study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. in addition, the aortic root is normal."
+"exam:  ct abdomen &#038; pelvis w&#038;wo contrast reason for exam:  status post aortobiiliac graft repair.  technique:  5 mm spiral thick spiral ct scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  no oral or rectal contrast was utilized.  comparison is made with the prior ct abdomen and pelvis dated 10/20/05.  there has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 ap.  just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  the size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  there is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  no exoluminal leakage is identified at any level.  there is no retroperitoneal hematoma present.  the findings are unchanged from the prior exam.   the liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  there is advanced atrophy of the left kidney.  no hydronephrosis is present.  no acute findings are identified elsewhere in the abdomen.  the lung bases are clear.  concerning the remainder of the pelvis, no acute pathology is identified.  there is prominent streak artifact from the left total hip replacement.  there is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  the bladder grossly appears normal.  a hysterectomy has been performed.   impression:1.  no complications identified regarding endoluminal aortoiliac graft repair as described.  the findings are stable compared to the study of 10/20/04.  2.  stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  3.  no other acute findings noted. 4.  advanced left renal atrophy."
+"preoperative diagnoses:1.  hematochezia.2.  refractory dyspepsia. postoperative diagnoses:1.  colonic polyps at 35 cm and 15 cm.2.  diverticulosis coli.2.  acute and chronic gastritis. procedure performed:1.  colonoscopy to cecum with snare polypectomy.2.  esophagogastroduodenoscopy with biopsies. indications for procedures:  this is a 43-year-old white male who presents as an outpatient to the general surgery service with hematochezia with no explainable source at the anal verge.  he also had refractory dyspepsia despite b.i.d., nexium therapy.  the patient does use alcohol and tobacco.  the patient gave informed consent for the procedure. gross findings:  at the time of colonoscopy, the entire length of colon was visualized.  the patient was found to have a sigmoid diverticulosis.  he also was found to have some colonic polyps at 35 cm and 15 cm.  the polyps were large enough to be treated with snare cautery technique.  the polyps were achieved and submitted to pathology.  egd did confirm acute and chronic gastritis.  the biopsies were performed for h&#038;e and clo testing.  the patient had no evidence of distal esophagitis or ulcers.  no mass lesions were seen. procedure:  the patient was taken to the endoscopy suite with the heart and lungs examination unremarkable.  the vital signs were monitored and found to be stable throughout the procedure.  the patient was placed in the left lateral position where intravenous demerol and versed were given in a titrated fashion. the video olympus colonoscope was advanced per anus and without difficulty to the level of cecum.  photographic documentation of the diverticulosis and polyps were obtained.  the patient&#8217;s polyps were removed in a similar fashion, each removed with snare cautery.  the polyps were encircled at their stalk.  increasing the tension and cautery was applied as coagulation and cutting blunt mode, 15/15 was utilized.  good blanching was seen.  the polyp was retrieved with the suction port of the scope.  the patient was re-scoped to the polyp levels to confirm that there was no evidence of perforation or bleeding at the polypectomy site.  diverticulosis coli was also noted.  with colonoscopy completed, the patient was then turned for egd.  the oropharynx was previously anesthetized with cetacaine spray and a biteblock was placed.  video olympus gif gastroscope model was inserted per os and advanced without difficulty through the hypopharynx.  the esophagus revealed a ge junction at 39 cm.  the ge junction was grossly within normal limits.  the stomach was entered and distended with air.  acute and chronic gastritis features as stated were appreciated.  the pylorus was traversed with normal duodenum.  the stomach was again reentered.  retroflex maneuver of the scope confirmed that there was no evidence of hiatal hernia.  there were no ulcers or mass lesions seen.  the patient had biopsy performed of the antrum for h&#038;e and clo testing.  there was no evidence of untoward bleeding at biopsy sites.  insufflated air was removed with withdrawal of the scope.  the patient will be placed on a reflux diet, given instruction and information on nexium usage.  additional recommendations will follow pending biopsy results.  he is to also abstain from alcohol and tobacco.  he will require follow-up colonoscopy again in three years for polyp disease."
+"preoperative diagnosis:  tremor, dystonic form. postoperative diagnosis:  tremor, dystonic form. complications:  none. estimated blood loss:  less than 100 ml. anesthesia:  mac (monitored anesthesia care) with local anesthesia. title of procedures:1.  left frontal craniotomy for placement of deep brain stimulator electrode.2.  right frontal craniotomy for placement of deep brain stimulator electrode.3.  microelectrode recording of deep brain structures.4.  stereotactic volumetric ct scan of head for target coordinate determination.5.  intraoperative programming and assessment of device. indications:  the patient is a 61-year-old woman with a history of dystonic tremor.  the movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  the procedure is discussed below. i have discussed with the patient in great deal the risks, benefits, and alternatives.  she fully accepted and consented to the procedure. procedure in detail:  the patient was brought to the holding area and to the operating room in stable condition.  she was placed on the operating table in seated position.  her head was shaved.  scalp was prepped with betadine and a leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% marcaine and 2% lidocaine in all planes.  iv antibiotics were administered as was the sedation.  she was then transported to the ct scan and stereotactic volumetric ct scan of the head was undertaken.  the images were then transported to the surgery planned work station where a 3-d reconstruction was performed and the target coordinates were then chosen.  target coordinates chosen were 20 mm to the left of the ac-pc midpoint, 3 mm anterior to the ac-pc midpoint, and 4 mm below the ac-pc midpoint.  each coordinate was then transported to the operating room as leksell coordinates. the patient was then placed on the operating table in a seated position once again.  foley catheter was placed, and she was secured to the table using the mayfield unit.  at this point then the patient&#8217;s right frontal and left parietal bossings were cleaned, shaved, and sterilized using betadine soap and paint in scrubbing fashion for 10 minutes.  sterile drapes placed around the perimeter of the field.  this same scalp region was then anesthetized with same local anesthetic mixture. a bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  bur holes were created on either side of the midline just behind the coronal suture.  hemostasis was controlled using bipolar and bovie, and self-retaining retractors had been placed in the field.  using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and stryker drill.  the bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  the cortical surface was then nicked with a #11 blade on both sides as well.  the leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  microelectrode drive was secured to the arc.  microelectrode recording was then performed.  the signatures of the cells were recognized.  microelectrode unit was removed.  deep brain stimulating electrode holding unit was mounted.  the dbs electrode was then loaded into target and intraoperative programming and testing was performed.  using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  this electrode was secured in position using bur-hole ring and cap system. attention was then turned to the left side, where left-sided coordinates were dialed into the system.  the microelectrode unit was then remounted.  microelectrode recording was then undertaken.  after multiple passes, the microelectrode unit was removed.  deep brain stimulator electrode holding unit was mounted at the desired trajectory.  the dbs electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  using standard parameters, the patient experienced similar results on her right side.  this electrode was secured using bur-hole ring and cap system.  the arc was then removed.  a subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel. we then closed the electrode, replaced subgaleally.  copious amounts of betadine irrigation were used.  hemostasis was controlled using the bipolar only.  closure was instituted using 3-0 vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  sterile dressings were applied.  the leksell arc was then removed. she was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  all needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses."
+"preoperative diagnoses:  prior history of anemia, abdominal bloating. postoperative diagnosis:  external hemorrhoids, otherwise unremarkable colonoscopy. premedications:  versed 5 mg, demerol 50 mg iv. report of procedure:  digital rectal exam revealed external hemorrhoids.  the colonoscope was inserted into the rectal ampulla and advanced to the cecum.  the position of the scope within the cecum was verified by identification of the appendiceal orifice.  the cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  the scope was retroflexed in the rectum and no abnormality was seen.  so the scope was straightened, withdrawn, and the procedure terminated. endoscopic impression:1.  normal colonoscopy.2.  external hemorrhoids."
+"admitting diagnoses1.  acute gastroenteritis.2.  nausea.3.  vomiting.4.  diarrhea.5.  gastrointestinal bleed.6.  dehydration. discharge diagnoses1.  acute gastroenteritis, resolved.2.  gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology. brief h&#038;p and hospital course:  this patient is a 56-year-old male, a patient of dr. x with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  this patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  the patient was admitted into the er and had trop x1 done, which was negative and ecg showed to be of normal sinus rhythm. lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for clostridium difficile and moderate amount of occult blood and moderate amount of rbcs.  the patient&#8217;s nausea, vomiting, and diarrhea did resolve during his hospital course.  was placed on iv fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  the patient also denied any abdominal pain upon day of discharge.  the patient was also started on prednisone as per gi recommendations.  he was started on 60 mg p.o.  amylase and lipase were also done which were normal and ldh and crp was also done which are also normal and lfts were done which were also normal as well. plan:  the plan is to discharge the patient home.  he can resume his home medications of prandin, actos, lipitor, glucophage, benicar, and advair.  we will also start him on a tapered dose of prednisone for 4 weeks.  we will start him on 15 mg p.o. for seven days.  then, week #2, we will start him on 40 mg for 1 week.  then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  he was instructed to take tapered dose of prednisone for 4 weeks as per the gi recommendations."
+"discharge diagnoses:1.  chest pain.  the patient ruled out for myocardial infarction on serial troponins.  result of nuclear stress test is pending.2.  elevated liver enzymes, etiology uncertain for an outpatient followup.3.  acid reflux disease. test done:  nuclear stress test, results of which are pending. hospital course:  this 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, o2 saturation at 94% with both atypical and typical features of ischemia.  the patient ruled out for myocardial infarction with serial troponins.  nuclear stress test has been done, results of which are pending.  the patient is stable to be discharged pending the results of nuclear stress test and cardiologist&#8217;s recommendations.  he will follow up with cardiologist, dr. x, in two weeks and with his primary physician in two to four weeks.  discharge medications will depend on results of nuclear stress test."
+"reason for visit:  followup on chronic kidney disease. history of present illness:  the patient is a 78-year-old gentleman with stage iii chronic kidney disease who on his last visit with me presented with classic anginal symptoms.  he was admitted to hospital and found to have an acute myocardial infarction.  he had a complex hospital course, which resulted in cardiac catheterization and two stents being placed.  his creatinine did pop above up to 3 but then came back to baseline.  his hospital stay was also complicated by urinary retention requiring a catheter and flomax.  he returns today to re-establish care.  of note, he was noted to have atrial fibrillation while hospitalized and had massive epistaxis. allergies:  none. medications:  starlix 120 mg b.i.d., compazine b.i.d., aspirin 81 mg daily, plavix 75 mg daily, glipizide 15 mg b.i.d., multivitamin daily, potassium 10 meq daily, cozaar 25 mg daily, prilosec 20 mg daily, digoxin 0.125 mg every other day, vitamin c 250 mg daily, ferrous sulphate 325 mg b.i.d., metoprolol 6.25 mg daily, lasix 80 mg b.i.d., flomax 0.4 mg daily, zocor 80 mg daily, and tylenol p.r.n. past medical history:1.  stage iii ckd with baseline creatinine in the 2 range.2.  status post mi on may 30, 2006.3.  coronary artery disease status post stents of the circumflex.4.  congestive heart failure.5.  atrial fibrillation.6.  copd.7.  diabetes.8.  anemia.9.  massive epistaxis. review of systems:  cardiovascular:  no chest pain.  he has occasional dyspnea on exertion.  no orthopnea.  no pnd.  he has occasional edema of his right leg.  he has been dizzy and his dose of metoprolol has been gradually decreased.  gu:  no hematuria, foamy urine, pyuria, frequency, dysuria, weak stream or dribbling. physical examination:  vital signs:  pulse 70.  blood pressure 114/58.  weight 79.5 kg.  general:  he is in no apparent distress.  heart:  irregularly irregular.  no murmurs, rubs, or gallops.  lungs:  clear bilaterally.  abdomen:  soft, nontender, and nondistended.  extremities:  trace edema on the right. laboratory data:  dated 07/05/06, hematocrit is 30.2, platelets 380, sodium 139, potassium 4.9, chloride 100, co2 28, bun 38, creatinine 2.2, glucose 226, calcium 9.7, and albumin 3.7. impression:1.  stage iii chronic kidney disease with return to baseline gfr of 31 ml/min.  he is on an arb.2.  coronary artery disease, status post stenting.3.  hypertension.  blood pressures are on the low side at present.  i hesitate to increase his cozaar although i would do this if tolerated in the future.4.  anemia of renal disease.  he is to start aranesp.5.  ? atrial fibrillation.  we discussed anticoagulation issues involved with chronic afib.  he may be popping in and out or this could just be a sinus arrhythmia. plan:1.  check ekg.2.  start aranesp 60 mcg every two weeks.3.  otherwise see him in four months.4.  if ekg shows atrial fibrillation, i wanted to talk to dr. xyz about coumadin."
+"cc: episodic mental status change and rue numbness, and chorea (found on exam). hx: this 78y/o rhm was referred for an episode of unusual behavior and rue numbness. in 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. evaluation at that time revealed an serum glucose of &gt;500mg/dl and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. his wife had taken over the family finances. he had also been &quot;stumbling,&quot; when ambulating, for 2 months prior to presentation. he was noted to be occasionally confused upon awakening for last several months. on 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. there had been no change in sleep, appetite, or complaint of depression. in addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of rue numbness. there was no face or lower extremity involvement. during the last year he had developed unusual movements of his extremities. meds: nph humulin 12u qam and 6u qpm. advil prn. pmh: 1) traumatic amputation of the 4th and 5th digits of his left hand.  2) hospitalized for an unknown &quot;nervous&quot; condition in the 1940&#8242;s. shx/fhx: retired small engine mechanic who worked in a poorly ventilated shop. married with 13 children. no history of etoh, tobacco or illicit drug use. father had tremors following a stroke. brother died of brain aneurysm. no history of depression, suicide, or huntington&#8217;s disease in family. ros: no history of cad, renal or liver disease, sob, chest pain, fevers, chills, night sweats or weight loss. no report of sign of bleeding. exam: bp138/63 hr65 rr15 36.1c ms: alert and oriented to self, season; but not date, year, or place. latent verbal responses and direction following. intact naming, but able to repeat only simple but not complex phrases. slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. knew the last 3 presidents. 14/27 on mmse: unable to spell &quot;world&quot; backwards. unable to read/write for complaint of inability to see without glasses. cn: ii-xii appeared grossly intact. eom were full and smooth and without unusual saccadic pursuits. okn intact. choreiform movements of the tongue were noted. motor: 5/5 strength throughout with guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. no motor impersistence noted. sensory: unreliable. cord: &quot;normal&quot; fnf, hks, and ram, bilaterally. station: no romberg sign. gait: unsteady and wide-based. reflexes: bue 2/2, patellar 2/2, ankles trace/trace, plantars were flexor bilaterally. gen exam: 2/6 systolic ejection murmur in aortic area. course: no family history of huntington&#8217;s disease could be elicited from relatives. brain ct, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. carotid duplex, 1/18/93: rica 0-15%, lica 16-49% stenosis and normal vertebral artery flow bilaterally. transthoracic echocardiogram (tte),1/18/93: revealed severe aortic fibrosis or valvular calcification with &quot;severe&quot; aortic stenosis in the face of &quot;normal&quot; lv function. cardiology felt the patient the patient had asymptomatic aortic stenosis. eeg, 1/20/93, showed low voltage delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. mri brain, 1/22/93: multiple focal and more confluent areas of increased t2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased t2 signal and decreased t1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. there were no masses or areas of abnormal enhancement. tsh, ft4, vit b12, vdrl, urine drug and heavy metal screens were unremarkable. csf,1/19/93: glucose 102 (serum glucose 162mg/dl), protein 45mg/dl, rbc o, wbc o, cultures negative. spep negative. however serum and csf beta2 microglobulin levels were elevated at 2.5 and 3.1mg/l, respectively. hematology felt these may have been false positives. cbc, 1/17/93: hgb 10.4g/dl (low), hct 31% (low), rbc 3/34mil/mm3 (low), wbc 5.8k/mm3, plt 201k/mm3. retic 30/1k/mm3 (normal). serum iron 35mcg/dl (low), tibc 201mcg/dl (low), fesat 17% (low), crp 0.1mg/dl (normal), esr 83mm/hr (high). bone marrow bx: normal with adequate iron stores. hematology felt the finding were compatible with anemia of chronic disease. neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. the pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. the patient was discharged1/22/93 on asa 325mg qd. he was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia."
+"reason for consultation:  lethargy. history of present illness:  the patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for pe, dvt, hyperlipidemia, and hypertension who is according to the patient&#8217;s daughter expressing signs of depression.  symptoms began on february 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  the patient&#8217;s appetite is unknown since she had been fed by ng tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  prior to receiving the news for needing more cancer therapy, the patient was described as being &quot;fine,&quot; participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  has been on a daily dose of lexapro since january 08, 2007, was increased from 10 mg to 20 mg on january 24, 2007, which is her current dose.  has been on provigil 100 mg b.i.d. since february 06, 2007, but has not noticed an impact.  had been on zyprexa 2.5 mg p.o. q.p.m. from december 20, 2006, to february 01, 2007, but has been discontinued.  currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  also, denies any homicidal ideations. past psychiatric history:  was prescribed prozac for depression, felt during husband&#8217;s successful battle with prostate cancer.  never been diagnosed with psychiatric illness.  displayed some psychotic symptoms, status post craniotomy while in icu, treated with zyprexa and xanax during hospitalization in 2006. past medical history:  craniotomy november 2006 with subsequent csf infection of enterobacter, status post glioblastoma multiforme, pe, dvt, hypertension, siadh, and ivc filter.  no history of thyroid problems, seizures, strokes, or traumatic head injuries. home medications:  norvasc 5 mg daily, tricor 145 mg daily, aspirin one tablet daily, tylenol, and glucosamine chondroitin sulfate. current medications:  norvasc 10 mg p.o. daily, decadron injection 6 mg iv q.12h., colace 100 mg liquid b.i.d., cardura 2 mg p.o. daily, lexapro 20 mg p.o. daily, lopressor 50 mg p.o. q.12h., flagyl 500 mg via peg tube q.8h., modafinil 100 mg p.o. b.i.d., lovenox 60 mg subcu q.12h., insulin sliding scale, tylenol suppositories 650 mg rectal q.4h. p.r.n., and ambien 5 mg p.o. q.h.s. p.r.n. allergies:  phenytoin (stevens-johnson syndrome), codeine, novocain, unknown allergy. family medical history:  father had lung cancer, was smoker for 40 years.  father&#8217;s aunt have heart disease. social and developmental history:  currently lives with husband of 40 years in league city, has a masters in education, is a retired reading specialist which she did it for 33 years.  has one younger brother, one daughter.  denies use of tobacco, alcohol and illicit drugs.  the child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating. mental status examination:  the patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient&#8217;s daughter denied delusions and homicidal ideations.  positive for passive suicidal ideations and perceptions.  no auditory or visual hallucinations.  sensorium stuporous, did not answer orientation questions.  memory information, intelligence, judgment, and insight unknown. mini-mental status examination unable to be performed. assessment:  a 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent cns infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy. axis i:  depression, nos.  rule out depression secondary to general medical condition.axis ii:  deferred.axis iii:  craniotomy with subsequent csf infection, pe, dvt, and hypertension.axis iv:  hospitalization.axis v:  11. plan:  continue lexapro 20 mg p.o. daily.  discontinue provigil, begin ritalin 5 mg p.o. q.a.m. and q. noon. thank you for the consultation."
+"cc: fall with subsequent nausea and vomiting. hx: this 52 y/o rhm initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. he &quot;knew what he wanted to say, but could not say it.&quot; his speech was slurred and he found it difficult to control his tongue. examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. he could read, but could not write. he exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. he was thougth to have possible pick&#8217;s disease vs. cortical basal ganglia degeneration. on 11/18/94, he fell and was seen in neurology clinic on 11/23/94. eeg showed borderline background slowing and no other abnormalities. an mri on 11/8/94, revealed mild atrophy of the left temporal lobe. neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. these were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning. he reported consuming 8 beers on the evening of 1/1/95. on 1/2/95, at 9:30am, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. he subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. he was taken to the etc at uihc. skull films were negative and he was treated with iv compazine and iv fluid hydration and sent home. his nausea and vomiting persisted and he became generally weak. he returned to the etc at uihc on 1/5/95. hct scan revealed a right frontal sdh containing signs of both chronic and acute bleeding. meds: none. pmh: 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. he reportedly had brief loss of consciousness with no reported head injury. 2)progressive aphasia. in 10/93, he was able to draw blue prints and write checks for his family business, 3) left frontoparietal headache for 1.5 years prior to 10/94. headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present. fhx: no neurologic disease in family. shx: divorced and lives with girlfriend. one child by current girlfriend. he has 3 children with former wife. smoked more than 15 years ago. drinks 1-2 beers/day. former iron worker. exam: bp128/83, hr68, rr18, 36.5c. supine: bp142/71, hr64; sitting: bp127/73, hr91 and lightheaded. ms: appeared moderately distressed and persistently held his forehead. a&#038;o to person, place and time. dysarthric and dysphagic. non-fluent speech and able to say single syllable words such as &quot;up&quot; or &quot;down&quot;. he comprehended speech, but could not repeat or write. cn: pupils 4/3.5 decreasing to 2/2 on exposure to light. eom were full and smooth. optic disks were flat and without sign of hemorrhage. moderate facial apraxia, but had intact facial sensation. motor: 5/5 strength with normal muscle bulk and tone. sensory: no abnormalities noted. coord: decreased ram in the rue. he had difficulty mmicking movements and postures with his rue gait: nd. station: no truncal ataxia, but he had a slight rue upward drift. reflexes 2/2 bue, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally. rectal exam was unremarkable. the rest of the general physical exam was unremarkable. heent: atraumatic normocephalic skull. no carotid bruitts. course: pt, ptt, cbc, gs, ua and skull xr were negative. hct brain, revealed a left frontal sdh with acute and cronic componenets. he was markedly orthostatic during the first few days of his hospital stay. he was given a 3 day trial of florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. this improved still further with a trial of sigvaris pressure stockings. a second hct was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal sdh. he was discharged home. his ideomotor apraxia worsened by 1/96. he developed seizures and was treated with cbz. he progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. he was last seen in 10/96 and the working diagnosis was cbgd vs. pick&#8217;s disease."
+"discharge summary summary of treatment planning:  this discharge is at the family&#8217;s request. identified problems/outcomes:1.   depression.2.   high risk behavior.   the patient easily was very depressed and anxious with paranoia.  the patient has improved, but is at high risk for relapse.  she needs rtc level of care.   interventions:  a developmentally appropriate, group-oriented therapy program was the primary treatment modality.  the attending psychiatrist provided evaluation for and management of psychotropic medications.  the clinical therapist facilitated individual, group, and family therapy.   course in hospital:  the patient was in the hospital from 06/11/04 until 07/13/04.  the most prominent symptoms and behaviors while the patient was here were the following: perceptual disturbances, disorganized thoughts, she was suspicious at times, at some point she was complaining of audiovisual hallucinations.  she was quiet showing a flat affect, irritable, anxious and depressed moods, tearful at times, homesick, limited interaction with peers.  she was attending groups, however, was showing limited participation.  she was superficial, not really working too much on her issues, more focused on how soon she was going to be discharged more than working on her issues.  she stated &quot;strange feelings and sensations&quot;.  the patient has shown some improvement in general.  however, she is not completely stable yet, and she sometimes is of relapse.  she is probably just waiting for the discharge to the next level of care, which is the rtc program.  however, the patient&#8217;s family will not follow our recommendations in this respect at this point.   diagnostic and therapeutic test/evaluations:  a sleep-deprived eeg was done and was normal.  ekg was also done and it seems to be grossly normal as well.   consultations:  the patient was seen by one of our medical consultants for h&#038;p for clearance to continue psychiatric treatment.  basic blood work was done including basic metabolic panel, cbc, tsh, ua, and urine drug screen.  per our medical consultant, thyroid dysfunction by history, however, thyroid panel, t3, t4, and tsh results are within normal limits.  history of asthma, by history, and also history of heart murmur (not heard during h&#038;p exam).  cbc: hematocrit of 35.5, low; absolute monocytes of 0.5, high; otherwise essentially normal lab results.   final diagnosis:axis    i:        major depression, recurrent, with psychotic features.axis   ii:  deferred.axis  iii:        no acute major medical conditions.axis  iv:        psychosocial stressors.axis   v:         gaf: 50 to 60, current. conditions on discharge:  the patient is alert, oriented to time, place, person, and situation.  she denies suicidal or homicidal ideas at present exploration.  she denies perception disturbances.  she does not seem to be responding to internal stimuli at this point.  she verbally contracted for safety.   prognosis:  guarded. discharge plan:  the patient will be discharged per family&#8217;s request.  she will continue treatment at hospital.  the intake appointment will be on 07/21/04 at 2:00 p.m.   note: treatment team recommendation for the patient is rtc (residential treatment center) program.  however, legal guardian will not follow our recommendations at this point.   discharge instructions:  the patient should visit her family doctor, cardiologist, and ob/gyn doctor for regular annual checkups.  she should visit all of these doctors in regard to her lab results and/or her physical (medical conditions).  please see under consultations.   discharge medication:  seroquel 25 mg p.o. a.m. #30 pills no refills; seroquel 50 mg p.o. q.h.s; benadryl 50 mg p.o. q. 6h p.r.n. for anxiety or agitation #30 pills; wellbutrin xl 300 mg p.o. q.a.m.; vitamin e 400 iu p.o. q.d. #30 pills; restoril 25 mg p.o. p.r.n. for anxiety #16 pills.   note: watch for the possibility of galactorrhea.  of note: the patient had galactorrhea (lactation) as a side effect from the use of risperdal.  do not give risperdal.   the patient and patient&#8217;s legal guardian were well oriented by me, the therapist in charge, and nursing staff."
+"identifying data:  psychosis. history of present illness:  the patient is a 28-year-old samoan female who was her grandmother&#8217;s caretaker.  her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  she had lived with her parents and son, but parents removed son from the home, secondary to the patient&#8217;s erratic behavior.  recently, she was picked up by kent police department &quot;leaping on highway 99.&quot; past medical history:  ptsd, depression, and substance abuse. past surgical history:  unknown. allergies:  unknown. medications:  unknown. review of systems:  unable to obtain secondary to the patient being in seclusion. objective:  vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees fahrenheit.  general appearance, heent, and history and physical examination was unable to be obtained today, as patient was put into seclusion. laboratory data:  laboratory reviewed reveals a bmp, slightly elevated glucose at 100.2.  previous urine tox was positive for thc.  urinalysis was negative, but did note positive ua wbc&#8217;s.  cbc, slightly elevated leukocytosis at 12.0, normal range is 4 to 11. assessment and plan:axis i:  psychosis.  inpatient psychiatric team to follow.axis ii:  deferred.axis iii:  we were unable to perform physical examination on the patient today secondary to her being in seclusion.  laboratory was reviewed revealing leukocytosis, possibly secondary to a uti.  we will wait until the patient is out of seclusion to perform examination.  should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  we will followup with the patient should any new medical issues arise."
+"reason for visit:  the patient is a 74-year-old woman who presents for neurological consultation referred by dr. x.  she is accompanied to the appointment by her husband and together they give her history. history of present illness:  the patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  danish is her native language, but she has been in the united states for many many years and speaks fluent english, as does her husband. with respect to her walking and balance, she states &quot;i think i walk funny.&quot;  her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  she has difficulty stepping up on to things like a scale because of this imbalance.  she does not festinate.  her husband has noticed some slowing of her speed.  she does not need to use an assistive device.  she has occasional difficulty getting in and out of a car.  recently she has had more frequent falls.  in march of 2007, she fell when she was walking to the bedroom and broke her wrist.  since that time, she has not had any emergency room trips, but she has had other falls. with respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency. the patient does not have headaches. with respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, &quot;i do not feel as smart as i used to be.&quot;  she feels that her thinking has slowed down.  her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing. the patient has not had trouble with syncope.  she has had past episodes of vertigo, but not recently. past medical history:  significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  she has been on ambien, which is no longer been helpful.  she has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws. family history:  her father died with heart disease in his 60s and her mother died of colon cancer.  she has a sister who she believes is probably healthy.  she has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  she has two normal vaginal deliveries. social history:  she lives with her husband.  she is a nonsmoker and no history of drug or alcohol abuse.  she does drink two to three drinks daily.  she completed 12th grade. allergies:  codeine and sulfa. she has a living will and if unable to make decisions for herself, she would want her husband, vilheim to make decisions for her. medications:  premarin 0.625 mg p.o. q.o.d., aciphex 20 mg p.o. q. daily, toprol 50 mg p.o. q. daily, norvasc 5 mg p.o. q. daily, multivitamin, caltrate plus d, b-complex vitamins, calcium and magnesium, and vitamin c daily. major findings:  on examination today, this is a pleasant and healthy appearing woman.vital signs:  blood pressure 154/72, heart rate 87, and weight 153 pounds.  pain is 0/10.head:  head is normocephalic and atraumatic.  head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.spine:  spine is straight and nontender.  spinous processes are easily palpable.  she has very mild kyphosis, but no scoliosis.skin:  there are no neurocutaneous stigmata.cardiovascular exam:  regular rate and rhythm.  no carotid bruits.  no edema.  no murmur.  peripheral pulses are good.  lungs are clear.mental status:  assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  she scored 30/30 on the mmse when attention was tested with either spelling or calculations.  she had no difficulty with visual structures.cranial nerves:  pupils are equal.  extraocular movements are intact.  face is symmetric.  tongue and palate are midline.  jaw muscles strong.  cough is normal.  scm and shrug 5 and 5.  visual fields intact.motor exam:  normal for bulk, strength, and tone.  there was no drift or tremor.sensory exam:  intact for pinprick and proprioception.coordination:  normal for finger-to-nose.reflexes:  are 2+ throughout.gait:  assessed using the tinetti assessment tool.  she was fairly quick, but had some unsteadiness and a widened base.  she did not need an assistive device.  i gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28. review of x-rays:  mri was reviewed from june 26, 2008.  it shows mild ventriculomegaly with a trace expansion into the temporal horns.  the frontal horn span at the level of foramen of munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  the sylvian aqueduct is patent.  there is no pulsation artifact.  her corpus callosum is bowed and effaced.  she has a couple of small t2 signal abnormalities, but no significant periventricular signal change. assessment:  the patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus. problems/diagnoses:1.  possible adult hydrocephalus (331.5).2.  mild gait impairment (781.2).3.  mild cognitive slowing (290.0). plan:  i had a long discussion with the patient her husband. i think it is possible that the patient is developing symptomatic adult hydrocephalus.  at this point, her symptoms are fairly mild.  i explained to them the two methods of testing with csf drainage.  it is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and i described that test.  about 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  alternatively, i could bring her into the hospital for four days of csf drainage to determine whether she is likely to respond to shunt surgery.  this procedure carries a 2% to 3% risk of meningitis.  i also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol."
+"preoperative diagnosis:  acute appendicitis. postoperative diagnoses:1.  pelvic inflammatory disease.2.  periappendicitis. procedure performed:1.  laparoscopic appendectomy.2.  peritoneal toilet and photos. anesthesia:  general. complications:  none. estimated blood loss:  less than 10 cc. indications for procedure:  the patient is a 31-year-old african-american female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  she also had mild leukocytosis with bright blood cell count of 12,000.  the necessity for diagnostic laparoscopy was explained and possible appendectomy.  the patient is agreeable to proceed and signed preoperatively informed consent. procedure:  the patient was taken to the operative suite and placed in the supine position under general anesthesia by anesthesia department. the preoperative foley, antibiotics, and ng tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  a veress needle was introduced and 15 mm pneumoperitoneum is created with co2 insufflation.  at this point, the veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  a second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  with the aid of a laparoscope, the pelvis was visualized.  the ovaries are brought in views and photos are taken.  there is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  attention was then turned on the right lower quadrant.  the retrocecal appendix is freed with peritoneal adhesions removed with endoshears.  attention was turned to the suprapubic area.  the 12 mm port was introduced under direct visualization and the mesoappendix was identified.  a 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  next, ________ tube was used to obtain gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  next, attention was turned to the right upper quadrant.  there is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with fitz-hugh-curtis syndrome also a prior pelvic inflammatory disease.  all free fluid is aspirated and patient&#8217;s all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  once the ports are removed the pneumoperitoneum is allowed to escape for patient&#8217;s postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 vicryl suture on a ur-6 needle.  local anesthetic is infiltrated at l3 port sites for postoperative analgesia and #4-0 vicryl subcuticular closure is performed with undyed vicryl.  steri-strips are applied along with sterile dressings.  the patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum iv antibiotics in the general medical floor.  routine postoperative care will be continued on this patient."
+"procedure:  colonoscopy. preoperative diagnoses:  the patient is a 56-year-old female.  she was referred for a screening colonoscopy.  the patient has bowel movements every other day.  there is no blood in the stool, no abdominal pain.  she has hypertension, dyslipidemia, and gastroesophageal reflux disease.  she has had cesarean section twice in the past.  physical examination is unremarkable.  there is no family history of colon cancer. postoperative diagnosis:  diverticulosis. procedure in detail:  procedure and possible complications were explained to the patient.  ample opportunity was provided to her to ask questions.  informed consent was obtained.  she was placed in left lateral position.  inspection of perianal area was normal.  digital exam of the rectum was normal. video olympus colonoscope was introduced into the rectum.  the sigmoid colon is very tortuous.  the instrument was advanced to the cecum after placing the patient in a supine position.  the patient was well prepared and a good examination was possible.  the cecum was identified by the ileocecal valve and the appendiceal orifice.  images were taken.  the instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  few diverticula were encountered in the sigmoid and descending colon.  retroflex view of the rectum was unremarkable.  no polyps or malignancy was identified. after obtaining images, the air was suctioned.  instrument was withdrawn from the patient.  the patient tolerated the procedure well.  there were no complications. summary of findings:  colonoscopy was performed to cecum and demonstrates the following:1.  mild-to-moderate diverticulosis.2.   recommendation:1.  the patient was provided information on diverticulosis including dietary advice.2.  she was advised repeat colonoscopy after 10 years."
+"reason for consult:  evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety. history of present illness:  this is a 50-year-old male who was transferred from sugar land er to abcd hospital for admission to the micu for acute alcohol withdrawal.  the patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  he reported that he called 911 secondary to noticing bilious vomiting and dry heave.  the patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  he has been away from work secondary to alcohol cravings and drinking.  he has also experienced marital and family conflict as a result of his drinking habit.  on average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  he reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  his longest period of sobriety was one year, and this was due to the assistance of attending aa meetings.  the patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  he reports anxiety that is mostly related to concern about his wife&#8217;s illness and fear of his wife leaving him secondary to his drinking habits.  he denies depressive symptoms.  he denies any psychotic symptoms or perceptual disturbances.  there are no active symptoms of withdrawal at this time. past psychiatric history:  there are no previous psychiatric hospitalizations or evaluations.  the patient denies any history of suicidal attempts.  there is no history of inpatient rehabilitation programs.  he has attended aa for periodic moments throughout the past few years.  he has been treated with antabuse before. past medical history:  the patient has esophagitis, hypertension, and fatty liver (recently diagnosed). medications:  his outpatient medications include lotrel 30 mg p.o. q.a.m. and restoril 30 mg p.o. q.h.s. inpatient medications are vitamin supplements, potassium chloride, lovenox 40 mg subcutaneously daily, lactulose 30 ml q.8h., nexium 40 mg iv daily, ativan 1 mg iv p.r.n. q.6-8h. allergies:  no known drug allergies. family history:  distant relatives with alcohol dependance.  no other psychiatric illnesses in the family. social history:  the patient has been divorced twice.  he has two daughters one from each marriage, ages 15 and 22.  he works as a geologist at petrogas.  he has limited contact with his children.  he reports that his children&#8217;s mothers have turned them against him.  he and his wife have experienced marital discord secondary to his alcohol use.  his wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  there are no other illicit drugs except alcohol that the patient reports. physical examination:  vital signs:  temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83. mental status examination:  this is a well-groomed male.  he appears his stated age.  he is lying comfortably in bed.  there are no signs of emotional distress.  he is pleasant and engaging.  there are no psychomotor abnormalities.  no signs of tremulousness.  his speech is with normal rate, volume, and inflection.  mood is reportedly okay.  affect euthymic.  thought content, no suicidal or homicidal ideations.  no delusions.  thought perception, there are no auditory or visual hallucinations.  thought process, logical and goal directed.  insight and judgment are fair.  the patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body. laboratory data:  cbc:  wbc 5.77, h&#038;h 14 and 39.4 respectively, and platelets 102,000.  bmp:  sodium 140, potassium 3, chloride 104, bicarbonate 26, bun 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, pt 13.4, and inr 1.0.  lfts:  alt 64, ast 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  pfts within normal limits. imaging:  cat scan of the abdomen and pelvis reveals esophagitis and fatty liver.  no splenomegaly. assessment:  this is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  the patient currently has no signs of withdrawal.  the patient&#8217;s anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  the patient had severe insomnia that is likely secondary to alcohol use.  currently, there are no signs of primary anxiety disorder in this patient. diagnoses:  axis i:  alcohol dependence.axis ii:  deferred.axis iii:  fatty liver, esophagitis, and hypertension.axis iv:  marital discord, estranged from children.axis v:  global assessment of functioning equals 55. recommendations:1.  continue to taper off p.r.n. ativan and discontinue all ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  discontinue outpatient restoril.  the patient has been informed of the hazards of using benzodiazepines along with alcohol.2.  continue alcoholics anonymous meetings to maintain abstinence.3.  recommend starting campral 666 mg p.o. t.i.d. to reduce alcohol craving.4.  supplement with multivitamin, thiamine, and folate upon discharge and before.  marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  referral has been given to the patient and his wife for the sets of counseling #713-263-0829.5.  alcohol education and counseling provided during consultation.6.  trazodone 50 mg p.o. q.h.s. for insomnia.7.  follow up with pcp in 1 to 2 weeks."
+"cc: horizontal diplopia. hx:  this 67 y/orhm first began experiencing horizontal binocular diplopia 25 years prior to presentation in the neurology clinic. the diplopia began acutely and continued intermittently for one year. during this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. he received no treatment and the diplopia spontaneously resolved. he did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. the diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. it resolves when he covers one eye. it is worse when looking at distant objects and objects off to either side of midline. there are no other symptoms associated with the diplopia. pmh: 1)4vessel cabg and pacemaker placement, 4/84. 2)hypercholesterolemia. 3)bipolar affective d/o. fhx: htn, colon ca, and a daughter with unknown type of &quot;dystonia.&quot; shx: denied tobacco/etoh/illicit drug use. ros: no recent weight loss/fever/chills/night sweats/cp/sob. he occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods. meds: lithium 300mg bid, accupril 20mg bid, cellufresh ophthalmologic tears, asa 325mg qd. exam: bp216/108 hr72 rr14 wt81.6kg t36.6c ms: unremarkable. cn: horizontal binocular diplopia on lateral gaze in both directions. no other cn deficits noted. motor: 5/5 full strength throughout with normal muscle bulk and tone. sensory: unremarkable. coord: mild &quot;ataxia&quot; of ram (left &gt; right) station: no pronator drift or romberg sign gait: unremarkable. reflexes: 2/2 symmetric throughout. plantars (bilateral dorsiflexion) studies/course: gen screen: unremarkable. brain ct revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. this shows no mass effect, but demonstrates mild contrast enhancement. there are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. the midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). metastatic lesions could show calcification but one would expect to see some degree of edema. the long standing clinical history suggest the former (i.e. hemangioma). no surgical or neuroradiologic intervention was done and the patient was simply followed. he was lost to follow-up in 1993."
+"procedure:  esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy. indications for procedure:  a 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  currently, he has a fistula from his anterior abdominal wall out.  it does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  ct scans show thickened terminal ileum, which suggest that we are dealing with crohn&#8217;s disease.  endoscopy is being done to evaluate for crohn&#8217;s disease. medications:  general anesthesia. instrument:  olympus gif-160 and pcf-160. complications:  none. estimated blood loss:  less than 5 ml. findings:  with the patient in the supine position, intubated under general anesthesia.  the endoscope was inserted without difficulty into the hypopharynx.  the scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  lower esophageal sphincter was located at 40 cm from the central incisors.  it appeared normal and appeared to function normally.  the endoscope was advanced into the stomach, which was distended with excess air.  rugal folds were flattened completely.  there were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with crohn&#8217;s involvement of the stomach.  the endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  two additional biopsies were obtained in the antrum for clo testing.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated that part of the procedure well. the patient was turned and scope was changed for colonoscopy.  prior to colonoscopy, it was noted that there was a perianal fistula at 7 o&#8217;clock.  the colonoscope was then inserted into the anal verge.  the colonic clean out was excellent.  the scope was advanced without difficulty to the cecum.  the cecal area had multiple ulcers with exudate.  the ileocecal valve was markedly distorted.  biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  the colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  no fistulas were noted in the colon.  excess air was evacuated from the colon.  the scope was removed.  the patient tolerated the procedure well and was taken to recovery in satisfactory condition. impression:  normal esophagus and duodenum.  there were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  all these findings are consistent with crohn&#8217;s disease. plan:  begin prednisone 30 mg p.o. daily.  await ppd results and chest x-ray results, as well as cocci serology results.  if these are normal, then we would recommend remicade 5 mg/kg iv infusion.  we would start modulon 50 ml/h for 20 hours to reverse the malnutrition state of this boy.  check cmp and phosphate every monday, wednesday, and friday for receding syndrome noted by following potassium and phosphate.  we will discuss with dr. x possibly repeating the ct fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  he will need an upper gi to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  if he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with crohn&#8217;s in the small intestine that we cannot visualize with endoscopy."
+"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."
+"after going to see the patient at approximately 1 a.m. for tachypnea, the patient was noted to be sating 99 to 100% on face shield.  he was calm and his respiratory rate was approximately 20.  after discussion with the rapid response nurse, it was decided that we will watch him in his bed in our return to rounds on other patients.  approximately 30 minutes later, i heard over the hospital intercom there was code blue in mr. x&#8217;s room and i rapidly proceeded to his room and found the patient undergoing cardiopulmonary resuscitation.  he was being bag masked and chest compressions were being performed.  a quick consultation with his nurse informed me that the patient was sating 99 to 100%, asked to sit up.  his wife and the nurse helped him sit up.  when he sat up, he apparently vomited and afterwards quickly desatted and his heart rate went to zero, a code blue was called, when i arrived on the scene the crash cart was being moved into position, i helped the nurses attach the monitoring leads and defibrillation pads on the patient.  after, the pads were attached, we assessed his rhythm and found him to be in ventricular fibrillation.  i ordered a defibrillation at 120, which was followed by 2 minutes of cpr.  during 2 minutes cpr, one of epinephrine and one of atropine was given.  during this time, he was being bag mask ventilated and an anesthesiologist was consulted to gain a definitive airway.  on reassessment of rhythm, the patient was found to be asystolic and no pulse was felt in his femoral or carotid arteries.  cpr was continued again and another round of epinephrine and atropine were given.  during this time, the anesthesiologist arrived and an et tube was placed with positive co2 return and breath sounds were heard in both lungs bilaterally.  cpr was continued for approximately 20 minutes with a total of five of epinephrine, 3 of atropine, 2 bicarb, 1 of calcium, and 1 of magnesium being given.  he had positive ventilation during this time with bilateral breath sounds being monitored at each rhythm check in two-minute intervals between cpr.  after approximately 25 minutes, a junctional rhythm was seen on the monitor and the patient was found to have a weak pulse.  the pulse was soon lost and cpr was continued.  at the next evaluation between cpr, the patient was found to be back in atrial fibrillation with a positive pulse in his carotid, femoral and radial arteries.  at this time, the patient he was transported to the icu.  when the patient was transported to the icu, dr. a secondary resident and b, fifth year resident arrived on the seen and took over the running of the code.  in the icu, his cardiopulmonary resuscitation was continued for approximately 20 more minutes after rhythm was lost.  rhythm was eventually regained and arterial line was introduced that found good waveform and pressures.  the patient was in atrial fibrillation/flutter.  again, he was placed on epinephrine drip.  labs were sent and post resuscitation chest x-ray was ordered."
+"preoperative diagnoses:  1.  congenital chylous ascites and chylothorax.2.  rule out infradiaphragmatic lymphatic leak. postoperative diagnoses:  diffuse intestinal and mesenteric lymphangiectasia. anesthesia:  general. indication:  the patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  the patient has been treated somewhat successfully with tpn and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  last week, dr. x took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  however at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  dr. x opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  this was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  we met with his parents and talked to them about this, and he is here today for that attempt. operative findings:  the patient&#8217;s abdomen was relatively soft, minimally distended.  exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  what we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  it appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  there was about one quarter to one third of the jejunum that did not appear to be grossly involved, but i did not think that resection of three quarters of the patient&#8217;s small bowel would be viable surgical option.  instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that. the lymphatic abnormality was extensive.  they were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  they were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  no other major retroperitoneal structure or correctable structure was identified.  both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well. description of operation:  the patient was brought from the pediatric intensive care unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  we conducted a surgical time-out and reiterated all of the patient&#8217;s important identifying information and confirmed the operative plan as described above.  preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  as the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  the bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient&#8217;s chylous ascites.  the small bowel from the ligament of treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for the patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  we suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient&#8217;s abdominal incision with 4-0 pds on the posterior sheath and 3-0 pds on the anterior rectus sheath.  subcuticular 5-0 monocryl and steri-strips were used for skin closure. the patient tolerated the procedure well.  he lost minimal blood, but did lose approximately 100 ml of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  the patient was returned to the pediatric intensive care unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an intestinal transplantation center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time."
+"cc: fluctuating level of consciousness. hx: 59y/o male experienced a &quot;pop&quot; in his head on 10/10/92 while showering in cheyenne, wyoming. he was visiting his son at the time. he was found unconscious on the shower floor 1.5 hours later. his son then drove him back to iowa. since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. he presented at local hospital this am, 10/13/92. a hct there demonstrated a subarachnoid hemorrhage. he was then transferred to uihc. meds: none. pmh: 1) right hip and clavicle fractures many years ago. 2) all of his teeth have been removed. fhx: not noted. shx: cigar smoker. truck driver. exam:  bp 193/73.  hr 71.  rr 21.  temp 37.2c. ms: a&#038;o to person, place and time. no note regarding speech or thought process. cn: subhyaloid hemorrhages, ou. pupils 4/4 decreasing to 2/2 on exposure to light. face symmetric. tongue midline. gag response difficult to elicit. corneal responses not noted. motor: 5/5 strength throughout. sensory: intact pp/vib. reflexes: 2+/2+ throughout. plantars were flexor, bilaterally. gen exam: unremarkable. course: the patient underwent cerebral angiography on 10/13/92. this revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. the patient subsequently underwent clipping of this aneurysm. he recovery was complicated severe vasospasm and bacterial meningitis. hct on 10/19/92 revealed multiple low density areas in the left hemisphere in the laca-lpca watershed, left fronto-parietal area and left thalamic region. he was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. he was last seen 2/26/93 in neurosurgery clinic and had stable deficits."
+"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&#8217;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."
+"cc: found unresponsive. hx:   39 y/o rhf complained of a severe ha at 2am 11/4/92. it was unclear whether she had been having ha prior to this. she took an unknown analgesic, then vomited, then lay down in bed with her husband. when her husband awoke at 8am he found her unresponsive with &quot;stiff straight arms&quot; and a &quot;strange breathing pattern.&quot; a brain ct scan revealed a large intracranial mass. she was intubated and hyperventilated to abg (7.43/36/398). other local lab values included: wbc 9.8, rbc 3.74, hgb 13.8, hct 40.7, cr 0.5, bun 8.5, glucose 187, na 140, k 4.0, cl 107. she was given mannitol 1gm/kg iv load, dph 20mg/kg iv load, and transferred by helicopter to uihc. pmh: 1)myasthenia gravis for 15 years, s/p thymectomy meds: imuran, prednisone, mestinon, mannitol, dph, iv ns fhx/shx: married. tobacco 10 pack-year; quit nearly 10 years ago. etoh/substance abuse unknown. exam: 35.8f, 99bpm, bp117/72, mechanically ventilated at a rate of 22rpm on !00%fio2. unresponsive to verbal stimulation. cn: pupils 7mm/5mm and unresponsive to light (fixed). no spontaneous eye movement or blink to threat. no papilledema or intraocular hemorrhage noted. trace corneal reflexes bilaterally. no gag reflex. no oculocephalic reflex. motor/sensory: no spontaneous movement. on noxious stimulation (deep nail bed pressure) she either extended both upper extremities (rue&gt;lue), or withdrew the stimulated extremity (right &gt; left). gait/station/coordination no tested. reflexes: 1+ on right and 2+ on left with bilateral babinski signs. hct 11/4/92: large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . there is low parenchymal density within the white matter. a hyperdense ring lies peripherally and may represent hemorrhage or calcification. the mass demonstrates inhomogeneous enhancement with contrast. course: head of bed elevated to 30 degrees, mannitol and dph were continued. mri of brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. she underwent surgical resection of the tumor. pathological analysis was consistent with adenocarcinoma. gyn exam, ct abdomen and pelvis, bone scan were unremarkable. cxr revealed an right upper lobe lung nodule. she did not undergo thoracic biopsy due to poor condition. she received 3000 cgy cranial xrt in ten fractions and following this was discharged to a rehabilitation center. in march, 1993 the patient exhibited right ptosis, poor adduction and abduction od, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. she was ambulatory with an ataxic gait. she was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and t8 sensory level. mri brainstem/spine on that day revealed decreased t1 signal in the c2, c3, c6 vertebral bodies, increased t2 signal in the anterior medulla, and tectum, and spinal cord (c7-t3). following injection of gadolinium there was diffuse leptomeningeal enhancement from c7-t7 these findings were felt consistent with metastatic disease including possible leptomeningeal spread. neurosurgery and radiation oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. the patient was treated with decadron and analgesics and discharged to a hospice center (her choice). she died a few months later."
+"cc: headache hx: 37 y/o rhf presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. the headachese were dull to throbbing in character. she was initially treated with parafon-forte for tension type headaches, but the pain did not resolve. she subsequently underwent hct in early 12/90 which revealed a right frontal mass lesion. pmh: 1)s/p tonsillectomy. 2)s/p elective abortion. fhx: mother with breast ca, ma with &quot;bone cancer.&quot; aodm both sides of family. shx: denied tobacco or illicit drug use. rarely consumes etoh. married with 2 teenage children. exam: vital signs unremarkable. ms: alert and oriented to person, place, time. lucid thought process per nsg note. cn: unremarkable. motor: full strength with normal muscle bulk and tone. sensory: unremarkable. coordination: unremarkable. station/gait: unremarkable. reflexes: unremarkable. gen. exam: unremarkable. course: mri brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. there is apparent tumor extension into the corpus callosum across the midline. tumor extension is also suggested in the anterior limb of the interanl capsule on the right. there is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. the mri findings are most consistent with glioblastoma. the patient underwent right frontal lobectomy. the pathological diagnosis was xanthomatous astrocytoma. the literature at the time was not clear as to optimal treatment protocol. people have survived as long as 25 years after diagnosis with this type of tumor. xrt was deferred until 11/91 when an mri and pet scan suggested extension of the tumor. she then received 5580 cgy of xrt in divided segments. she developed olfactory auras shortly after lobectomy at was treated with pb with subsequent improvement. she was treated with bcnu chemotherapy protocol in 1992."
+"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, &quot;it&#8217;s an accident.&quot;  she sees him as impulsive on the weekends, but is not sure if this just isn&#8217;t &quot;all boy.&quot; 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&#8217;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 &quot;s&quot; 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&#8217;s behavior was &quot;weird.&quot;  biological father&#8217;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 &quot;all wisdom.&quot; 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, &quot;no.&quot;  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, &quot;god is.&quot;  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, &quot;yes.&quot;  when asked who he talks to if he is hurt or upset, he stated, &quot;mom.&quot;  (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, &quot;get out!&quot;  insight was poor to adequate.  fund of information was good.  when asked who the president was, he said, &quot;george washington.&quot; 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&#8242;s he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3&#8242;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&#8217;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. clinical impression:  it is difficult to know until he is trialed off medication whether or not he truly has attention deficit or oppositional behavior, due to mother has since the last appointment created a lot of structure in her life.  she has implemented some parenting techniques, love and logic by foster cline and 1-2-3 magic by dr. p, in which she is carrying out pretty consistently and it seems that abcd is doing much better with his behavior since she has instituted these.  he is also doing well in school, but he is on medication when he is in school.  the medication is causing him some distress in that he is not sleeping at night.  he could have an underlying mood disorder and that is what is manifesting with the insomnia, due to he does not receive the medication on the weekends and still has problems going to sleep.  there is a possibility abcd could have an underlying mood disorder with mother being assessed for bipolar and due to the history of father&#8217;s risk-taking behaviors, drug and alcohol use, as well as impulsivity.  also mother reports that if things get too noisy or too chaotic around abcd, he will report that his head hurts or that he feels there is too much going into his head. diagnoses:axis  i  at this point in time we are in an investigative time, so will give:  312.9  disruptive behavior disorder, nos (not otherwise specified).  314.01 adhd (attention-deficit hyperactivity disorder), combined, by history.  rule out mood disorder.axis  ii  none.axis iii  none.axis iv  problems with primary support group.axis v  gaf:  65, current. prognosis:good, due to mother and significant other are very invested in abcd&#8217;s care. plan:  trial off the concerta.  i gave mother the nichq vanderbilt assessment scales thatscreen for adhd, as well as anxiety, oppositional defiant disorder, conduct disorder, depression, and mood.  we will have mother and richard, as well as teachers, screen him on medication and off medication.  encouraged mother to continue with the love and logic and 1-2-3 magic parenting techniques. follow up will be in three weeks.  the parents were given the option that they may cancel the appointment if he his stable off medication.  if he has difficulty being off medication, before any more prescriptions will be written, we would want to see the assessments from the nichq vanderbilt assessment scales."
+"<strong>indication: </strong>rectal bleeding, constipation, abnormal ct scan, rule out inflammatory bowel disease. <strong>premedication: </strong>see procedure nurse ncs form. <strong>procedure: </strong>after informed consent was obtained, the patient was placed in the left lateral position and the above medications were titrated with adequate sedation. monitoring was provided throughout the entire procedure. digital rectal exam was performed revealing normal sphincter tone and no external hemorrhoids. the pentax video colonoscope was inserted into rectum and advanced under direct visualization, without difficulty, to the cecum, where the cecal strap, appendiceal orifice, and the ileocecal valve were identified. the quality of the preparation was good. the colonoscope was then withdrawn while carefully examining the mucosa. the colonic mucosa appeared normal with normal vascularity and haustral markings. no masses, polyps, avm/s or diverticula were seen. on retroflexed view in the rectum, there are small internal hemorrhoids. the endoscope was removed and the procedure terminated. the patient tolerated the procedure well without complications. <strong>impression: </strong> 1. small internal hemorrhoids. 2. otherwise normal colonoscopy. <strong>plan: </strong>continue fiber, increase to two tablets twice a day for a total of four tablets. also try nulev. <strong>followup: </strong>in the office in approximately four weeks if her symptoms do not resolve."
+"reason for referral:  the patient was referred for a neuropsychological evaluation by dr. x.  a comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope. brief summary &#038; impressions: relevant history:historical information was obtained from a review of available medical records and an interview with the patient. the patient presented to dr. x on august 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  she was referred to dr. x for diagnostic differentiation for possible seizures or other causes of syncope.  the patient reports an extensive neurological history.  her mother used alcohol during her pregnancy with the patient.  in spite of exposure to alcohol in utero, the patient reported that she achieved &quot;honors in school&quot; and &quot;looked smart.&quot;  she reported that she began to experience migraines at 11 years of age.  at 15 years of age, she reported that she was thought to have hydrocephalus.  she reported that she will frequently &quot;bang her head against the wall&quot; to relieve the pain.  the patient gave birth to her daughter at 17 years of age.  at 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  she reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and &quot;thrown two and a half city blocks.&quot;  the patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  she reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  her migraines became more severe following the head injury.  in 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  following the syncope episode, she would experience some confusion.  these episodes reportedly were related to her donating plasma. the patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  she reported that upon awakening, she would feel off balanced and somewhat confused.  these episodes diminished from 2002 to june 2008.  when making dinner, she suddenly dropped and hit the back of her head on refrigerator.  she reported that she was unconscious for five to six minutes.  a second episode occurred on july 20th when she lost consciousness for may be a full day.  she was admitted to sinai hospital and assessed by a neurologist.  her eeg and head ct were considered to be completely normal.  she did not report any typical episodes during the time of her 36-hour eeg.  she reported that her last episode of syncope occurred prior to her being hospitalized.  she stated that she had an aura of her ears ringing, vision being darker and &quot;tunnel vision&quot; (vision goes smaller to a pinpoint), and she was &quot;spazzing out&quot; on the floor.  during these episodes, she reports that she cannot talk and has difficulty understanding. the patient also reports that she has experienced some insomnia since she was 6 years old.  she reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of jack daniel.  she stopped the use of alcohol and that time she experienced a suicide attempt.  in 2002, she was diagnosed with bipolar disorder and was started on medication.  at the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  the patient&#8217;s medical history is also significant for postpartum depression. the patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  she reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  she finds that she often has difficulty with expressing her thoughts, as she is very tangential.  she experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  she reported that she had a photographic memory for directions.  she said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  at the present time, her daughter has now moved on to college.  the patient is living with her biological mother.  although she is going through divorce, she reported that it was not really stressful.  she reported that she spends her day driving other people around and trying to be helpful to them. at the time of the neuropsychological evaluation, the patient&#8217;s medication included ativan, imitrex, levoxyl, vitamin b12, albuterol metered dose inhaler as needed, and zofran as needed.  (it should be noted that the patient by the time of the feedback on september 19, 2008 had resumed taking her trileptal for bipolar disorder.).  the patient&#8217;s familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol. tests administered:clinical interviewcognistatmattis dementia rating scalewechsler adult intelligence scale &#8211; iii (wais-iii)wechsler abbreviated scale of intelligence (wasi)selected subtests from the delis kaplan executive function system (dkefs)  trail making test  verbal fluency (letter fluency &#038; category fluency)  design fluency  color-word interference test  towerwisconsin card sorting test (wcst)stroop testcolor trailstrails a &#038; btest of variables of attentionmultilingual aphasia examination ii  token test  sentence repetition  visual naming  controlled oral word association  spelling test  aural comprehension  reading comprehensionboston naming test-2 (bnt-2)animal naming testthe beery-buktenica developmental test of visual-motor integration (vmi)the beery-buktenica developmental test of motor coordinationthe beery-buktenica developmental test of visual perceptionjudgment line orientationgrooved pegboardpurdue pegboardfinger tapping testrey complex figurewechsler memory scale -iii (wms-iii)california verbal learning testwoodcock johnson achievement test iiiwide range achievement test &#8211; ivbeck  depression inventory (bdi)state-trait inventory (staic)adult history questionnairebehavior rating inventory of executive function (brief)adaptive behavior assessment system behavior observations:  the patient presented as a well-dressed and african-american woman who developed a rapport with the examiner.  she appeared somewhat anxious and started the evaluation on the edge of her chair, although she eventually tended to relax more.  overall, her affect and mood were appropriate for the evaluation.  her speech was slightly above normal for rate, speed, and intensity.  she was slightly tangential.  she appeared to have no difficulty comprehending or expressing herself.  her performance was notable for poor cognitive flexibility and impulsivity.  she also demonstrated mild psychomotor slowing.  the patient was right-handed for writing and drawing.  overall, she demonstrated adequate rates of attention/concentration, cooperation, and perseverance.  therefore, the following evaluation is considered to be an accurate reflection of her current cognitive abilities. evaluation findings:classification level    percentile rank    standard score    scaled score    t-scoresuperior                          &gt; 95                            120                      &gt; 14               &gt; 66high average                 76-95                        11-124                  13-14             58-66average                          25-75                        90-110                    8-12             44-57low average                   9-24                          80-89                       7                 37-43borderline                        9-10                          70-79                       6                30-36mildly impaired                  5-8                           &lt; 70                      4-5                &lt; 30moderately impaired         2-4                                                          3  deficient/impaired             &lt; 2                                                         1-2   orientation:  the patient was oriented to person, place, and time. general cognitive ability:  the patient&#8217;s overall intellectual ability fell in the average range.  there was no statistically significant discrepancy between her verbal and her performance (nonverbal) intellect. attention/ executive function:  the patient did well on measures of verbal and design fluency as her performance fell in the average range.  on a trial making task, she did well on all versions of the test including number, letter sequencing with the exception of the motor speed task.  on this measure, she did not listen fully to the instructions and reduced her speed.  on a color word interference task, her performance for inhibiting responses fell in low average range and was a subtle change from her high end of average performance on color naming and word reading.  on measures of visual and verbal working memory, her performance was solidly in the average range. the patient completed a valid behavior rating inventory of executive functioning.  on this measure, she indicated that she was experiencing difficulties with cognitive inflexibility, emotional dyscontrol, and poor working memory. language function:  the patient had a difficulty with measures that are related more to verbal comprehension.  she had significant difficulty with repeating sentences and difficulty with following commands.  on the command comprehension measure, she had difficulty with sequencing and two-step commands.  on sentence repetition, she had difficulty remembering the details of the sentence that she repeated.  on a naming to command measure, her performance fell in the average range and on the verbal fluency measure both semantic and phonemic, her performance fell in the average range.  overall, this pattern of performance suggests mild receptive language difficulties and difficulty with sequencing. visual-spatial &#038; visual-motor function:  on a visual spatial discrimination task, her performance fell solidly in the average range.  on a measure of fine motor manual dexterity, her right hand and left hand performance fell in the average range and when she was required to use both hands simultaneously, her performance decreased slightly into the low average range. learning &#038; memory skills:  on a five-trial 16-item verbal list learning measure, the patient&#8217;s rate of acquisition fell in the high average range.  when a interference list was introduced, she had some difficulty learning the interference list as she could only recall 25% of the words.  however, following the introduction of this list, she was still able to recall 15 of the 16 words from the original list.  following a 20-minute delay, she was able to recall 15 of the 16 words.  she entirely used a semantic cluster strategy.  overall, her performance fell in the high average range on this measure.  on a story (prose) verbal memory measure, her immediate and delayed (30 minute) recall both fell in the high average range. on the copy of the complex geometric design, her visual spatial organization was poor and her performance fell in the low average range.  her immediate recall of the design fell in the borderline range and following a 30-minute delay, she lost even more details to decline into the mildly impaired range.  in general, her copy of the design was notable for its lack of overall configuration and good stop.  her immediate recall failed to maintain a good stop overall configuration design and was void of details.  the design further decompensated after a 30-minute delay as she lost further configuration and details.  it is thought that her poor performance on this could represent some difficulty in visual memory, but most likely is due to poor initial encoding and organization of the design.  on facial recognition task, her immediate recognition of the faces fell in the high average range.  following a 30-minute delay, though her performance declined to the low end of average, this is a significant discrepancy and suggested that she did have difficulty retaining and retrieving the information that she had stored.  therefore, a subtle mild weakness is in visual spatial memory. academic function: behavioral/emotional function:  the patient was administered a mmpi-2.  her responses unfortunately were completely invalid due to an over endorsement of symptoms.  typically, an over endorsement of symptoms is indicative of significant affective distress or a need for attention.  on this measure, the patient reported an elevated level of affective distress and unusual ideation.  her profile is consistent with patients who may demonstrate their affective distress through physical means.  overall, this pattern should be interpreted very cautiously due to the invalid nature of the profile. summary &#038; impressions:  the patient was referred by neurologist for a neuropsychological evaluation for diagnostic clarity, and specific recommendations for medical and psychological intervention in light of undiagnosed episodes of syncope. in summary, the patient&#8217;s neuropsychological evaluation revealed selective deficits of executive system dysfunction, mild receptive language difficulties (partially due to executive system dysfunction) and subtle visual memory storage and retrieval superimposed upon an average level of intellect.  her mmpi-2 was invalid, but indicated that she was undergoing significant stress and that she is more likely to demonstrate her stress through physical and cognitive rather than emotional display. the patient&#8217;s neurobehavioral risk factors are significant for chronic history of migraines, bipolar disorder, depression, reported in utero exposure to alcohol, history of heavy substance abuse, and use of neuropsychiatric medication.  bipolar affective disorder is known to impact executive system dysfunction as patients have difficulty with impulsivity, cognitive flexibility, working memory, emotional control, and self-monitoring.  the patient&#8217;s performance is certainly consistent with this report.  medication can also have an effect on executive system functioning and attention/concentration.  despite this, it is far better for her to have access to neuropsychiatric medication to balance her mood swings.  there was some mild evidence of decreased visual spatial memory for retrieval in contrast to high average verbal memory.  although she had difficulty on measures of comprehension, it was likely due to decreased attention and concentration given that she was able to perform other tasks that require receptive language very well (verbal memory).  given the patient&#8217;s history, she has done extraordinarily well and many of her cognitive abilities are intact, which allow her to function at a very high level.  it is strongly recommended that she share these results with her psychiatrist/psychologist to assist in any treatment planning for her and to continue to make positive and achievable goals for the patient. you may wish to consider the following recommendations to improve the patient&#8217;s quality of life. recommendations:medical:1.  please share these results with dr. x to determine any need to change in her medical treatment.2.  it is critical that the patient take care of herself and reduce her distress.  in particular, she should make sure that she has a normalized sleeping pattern and she is eating appropriately and getting appropriate rest.psychological:1.  she should share these results with her psychiatrist/psychologist, to assess for any change in her current psychological treatment.2.  it is likely that the patient will need to stay on medication to treat her bipolar disorder.  bipolar disorder does not go into remission and sadly is a chronic disorder.3.  in psychotherapy, it is important for goals to be set for the patient and that she can achieve those goals.  it is apparent that she is frequently feeling overwhelmed and does not understand how to be able to take care of herself and ways that are not needing medical care.  goals to increase her sleep and reduce her stress may be fundamental, but are certainly required in her case. occupational:  the patient has many strong abilities and with balance of her emotional life, there is no reason why she cannot return to work.  her work setting should be in a well structured place with minimal multitasking and will keep a people contact."
+"cc: motor vehicle-bicycle collision. hx: a 5 y/o boy admitted 10/17/92. he was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. first responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. he had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. he was intubated and ventilated in the field, and then transferred to uihc. pmh/fhx/shx: unremarkable. meds: none exam: bp 127/91 hr69 rr30 ms: unconscious and intubated glasgow coma scale=4 cn: pupils 6/6 fixed. corneal reflex: trace od, absent os. gag present on manipulation of endotracheal tube. motor/sensory: bilateral decorticate posturing to noxious stimulation (chest). reflexes: bilaterally. laceration of mid forehead exposing calvarium. course: emergent brain ct scan revealed: displaced fracture of left calvarium. left frontoparietal intraparenchymal hemorrhage. right ventricular collection of blood. right cerebral intraparenchymal hemorrhage. significant mass effect with deviation of the midline structures to right. the left ventricle was compressed with obliteration of the suprasellar cistern. air within the soft tissues in the left infra temporal region. c-spine xr, abdominal/chest ct were unremarkable. patient was taken to the or emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. he was given mannitol enroute to the or and hyperventilated during and after the procedure. postoperatively he continued to manifest decerebrate posturing . on 11/16/92 he underwent vp shunting with little subsequent change in his neurological status. on 11/23/92 he underwent tracheostomy. on 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. by the time of discharge, 1/14/93, he tracked relatively well od, but had a cn3 palsy os. he had relatively severe extensor rigidity in all extremities (r&gt;l). his tracheotomy was closed prior to discharge. a 11/16/92 brain mri demonstrated infarction in the upper brain stem (particularly in the pons), left cerebellum, right basil ganglia and thalamus. he was initially treated for seizure prophylaxis with dph, but developed neutropenia, so it was discontinued. he developed seizures within several months of discharge and was placed on vpa (depakene). this decreased seizure frequency but his liver enzymes became elevated and he changed over to tegretol. 10/8/93 brain mri (one year after mva) revealed interval appearance of hydrocephalus, abnormal increased t2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. these findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma. he was last seen 10/30/96 in the pediatric neurology clinic&#8211;age 9 years. he was averaging 2-3 seizures per day&#8212;characterized by extension of bue with tremor and audible cry or laughter&#8212;on tegretol and diazepam. in addition he experiences 24-48hour periods of &quot;startle response (myoclonic movement of the shoulders)&quot; with or without stimulation every 6 weeks. he had limited communication skills (sparse speech). on exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia."
+"title of operation:  right-sided craniotomy for evacuation of a right frontal intracranial hemorrhage. indication for surgery:  the patient is very well known to our service.  in brief, the patient is status post orbitozygomatic resection of a pituitary tumor with a very large intracranial component basically a very large skull-based brain tumor.  he was taken to the operating room for the orbitozygomatic approach.  intraoperatively, everything went well without any complications.  the brain at the end of the procedure was absolutely intact, but the patient developed a seizure in the intensive care unit and then was taken to the ct scan, developed a second seizure.  he was given ativan for this, and then began to identify a large component measuring about 3 x 3 cm of the right frontal lobe, what appeared to be a hemorrhagic conversion of potential venous infarct.  i had a long discussion immediately with dr. x and dr. y.  we decided to take the patient immediately as a level 1 for evacuation of this hematoma with a small amount of a midline shift with an intraventricular component.  it worried me and i think that we needed to go ahead and take him to the operating room immediately.  the patient was taken as a level 1 immediately and emergently and into the operating room for this procedure.  the original plan was to do first a right-sided orbitozygomatic procedure and then stage it a few weeks later with an endonasal endoscopic procedure for resection of this pituitary tumor component.  he was taken to the operating room for evacuation of a right frontal intraparenchymal hematoma. preop diagnosis:  pituitary tumor with a large intracranial component, status post resection and now development of an intracranial hemorrhage. postop diagnosis:  intracranial hemorrhage in the right frontal lobe with extension into the intraventricular space after resection of a pituitary tumor via orbitozygomatic approach. anesthesia:  general. procedure in detail:  the patient was taken to the operating room.  in the supine position, his head was put in a horseshoe without any complications.  the patient tolerated this very well, and the prior incision was immediately opened.  the surgery had taken place a few hours prior to this, the original orbitozygomatic approach.  at this point, this was a life-saving procedure.  we went ahead, opened the old incision after everything was sterilely prepped, and all the surgical instrumentation was brought into place.  we went ahead and opened the incision and took out the pterional bone flap without any complications.  we immediately opened the dura expeditiously, and the brain was moderately under some pressure, but not really bulging out.  so i went ahead and identified an area over the right frontal lobe that was a little bit consistent with a hemorrhagic infarct and nonviable tissue.  so we went ahead and did a corticectomy right there and identified the actual clot immediately and went ahead, and over the next few hours, very meticulously began to evacuate these clots without any complication whatsoever.  we went all the way down to the ventricle and identified this clot in the ventricle and went ahead and removed this clot without any complications, and we had a very nice resection.  the brain was very relaxed.  we had a very good resection of the actual blood clot, and the brain was very relaxed.  we irrigated thoroughly.  we identified the ventricles.  we went ahead and did a very careful hemostasis with avitene with thrombin and gelfoam with thrombin over the next times in doing the procedure.  all this was done very well, and then we lined the cavity with surgicel, and the surgicel was only put at the edge and draping down as to not to leave any fragments potentially to communicate with the actual ventricle, and then after this, everything was good.  we went ahead and closed back the actual dura back.  we had done a pericranial flap.  this was also put back in place and the dura was closed with 4-0 surgilons.  we reconstructed everything.  the frontal sinus was reconstructed thoroughly without any complications.  we went ahead and put once again a watertight closure and went ahead and put another piece of duragen with hemaseel in place, and went ahead and put the bone flap back and reconstructed very nicely once again with self-tapping, self-drilling screws, low-profile plates.  once everything was confirmed to be in place, we went ahead and closed the muscle flap and also the actual fat pad was put back into place and closed together with 0 pop-offs, and the skin with staples without any complications.  in summary, the procedure was going back to the operating room for evacuation of a right-sided intracranial hemorrhage, most likely a conversion of an intraparenchymal hematoma with extension into the ventricle without any complications.  so everything was stable.  estimated blood loss was about 100 cubic centimeters.  the sponges and needle counts were correct.  no specimens were sent to pathology. disposition:  the patient after this procedure was brought to the neuro intensive care unit for close observation."
+"cc: left hemiplegia. hx:  a 58 y/o rhf awoke at 1:00am on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. she was seen at a local er and neurological exam and ct brain were reportedly unremarkable. she was admitted locally. she then had two more similar spells at 3am and 11am with resolution of the symptoms within an hour. she was placed on iv heparin following the 3rd episode and was transferred to uihc. she had not been taking asa. pmh: 1)htn. 2) psoriasis. shx: denied etoh/tobacco/illicit drug use. fhx: unknown. meds: heparin only. exam: bp160/90 hr145 (supine). bp105/35 hr128 (light headed, standing) rr12 t37.7c ms: dysarthria only. lucid thought process. cn: left lower facial weakness only. motor: mild left hemiparesis with normal muscle bulk. mildly increased left sided muscle tone. sensory: unremarkable. coordination: impaired secondary to weakness on left. otherwise unremarkable. station: left pronator drift. romberg testing not done. gait: not tested. reflexes: symmetric; 2+ throughout. gen exam: cv: tachycardic without murmur. course: the patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. she was immediately placed in a reverse trendelenburg position and given iv fluids. repeat neurologic exam at 5pm on the day of presentation revealed a return to the initial presentation of signs and symptoms. pt/ptt/gs/cbc/abg were unremarkable. ekg revealed sinus tachycardia with rate dependent junctional changes. cxr unremarkable. mri brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the proton density weighted images. over the ensuing days of admission she had significant fluctuations of her bp (200mmhg to 140mmhg systolic). her symptoms worsened with falls in bp. her bp was initially controlled with esmolol or labetalol. renal ultrasound, abdominal/pelvic ct, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. carotid doppler study revealed 0-15%bica stenosis and antegrade vertebral artery flow, bilaterally. transthoracic echocardiogram was unremarkable. cerebral angiogram was performed to r/o vasculitis. this revealed narrowing of the m1 segment of the right mca. this was thought secondary to atherosclerosis and not vasculitis. she was discharged on asa, procardia xl, and labetalol."
+"exam:  ct of the abdomen and pelvis without contrast. history:  lower abdominal pain. findings:  limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  there is a 1.6 cm nodular density at the left posterior sulcus. noncontrast technique limits evaluation of the solid abdominal organs.  cardiomegaly and atherosclerotic calcifications are seen. hepatomegaly is observed.  there is calcification within the right lobe of the liver likely related to granulomatous changes.  subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  there is splenomegaly seen.  there are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  the pancreas appears atrophic.  there is a left renal nodule seen, which measures 1.9 cm with a hounsfield unit density of approximately 29, which is indeterminate. there is mild bilateral perinephric stranding.  there is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  there is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  bilateral ureters appear normal in caliber along their visualized course.  the bladder is partially distended with urine, but otherwise unremarkable. postsurgical changes of hysterectomy are noted.  there are pelvic phlebolith seen.  there is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein. scattered colonic diverticula are observed.  the appendix is within normal limits.  the small bowel is unremarkable.  there is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  the hernia neck measures approximately 2.7 cm.  there is stranding of the fat within the hernia sac. there are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  degenerative changes of the spine are observed. impression:1.  anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.2.  nodule in the left lower lobe, recommend follow up in 3 months.3.  indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol ct or mri.4.  hepatomegaly with changes suggestive of cirrhosis.  there is also splenomegaly observed.5.  low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.6.  fat density lesion in the left kidney, likely represents angiomyolipoma.7.  fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst."
+"procedure performed:1.  right femoral artery access.2.  selective right and left coronary angiogram.3.  left heart catheterization.4.  left ventriculogram. indications for procedure:  a 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  the resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported lvef of 20% to 25%.  this was a sharp decline from a previous lvef of 50% to 55%.  we therefore, decided to proceed with coronary angiography. technique:  after obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  the right groin was prepped and draped in the usual sterile manner.  2% lidocaine was used for infiltration anesthesia.  using modified seldinger technique, a 6-french sheath was introduced into the right femoral artery.  6-french jl4 and jr4 diagnostic catheters were used to perform the left and right coronary angiogram.  a 6-french pigtail catheter was used to perform the lv-gram in the rao projection. hemodynamic data:  lvedp of 11.  there was no gradient across the aortic valve upon pullback. angiographic findings:1.  the left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.2.  the left main coronary artery is free of any disease.3.  the left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  the first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.4.  the second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  one of its secondary branches which is a small caliber has an ostial 70% stenosis.5.  the left anterior descending artery has a patent stent in the proximal lad.  the second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  there appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  the diagonal branches are free of any disease.6.  the right coronary artery is a dominant vessel and has mild luminal irregularities.  its midsegment has a focal area of 30% narrowing as well.  the rest of the right coronary artery is free of any disease.7.  the lv-gram performed in the rao projection shows well preserved left ventricular systolic function with an estimated lvef of 55%. recommendation:  continue with optimum medical therapy.  because of the discrepancy between the left ventriculogram ef assessment and the echocardiographic ef assessment, i have discussed this matter with dr. xyz and we have decided to proceed with a repeat 2d echocardiogram.  the mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia."
+"procedure:  right ventricular pacemaker lead placement and lead revision. indications:  sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead. equipment:  a new lead is a medtronic model #507652, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  the original chronic ventricular lead had a threshold of 3.5 and 6 on the can. estimated blood loss:  5 ml. procedure description:  conscious sedation with versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  the patient received a venogram documenting patency of the subclavian vein.  skin incision with blunt and sharp dissection.  electrocautery for hemostasis.  the pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  the leads were sequentially checked.  through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  pocket was irrigated with antibiotic solution.  the pocket was packed with bacitracin-soaked gauze.  this was removed during the case and then irrigated once again.  the generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 monocryl. conclusion:   successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous vitatron pulse generator model # c60a1b."
+"cc: difficulty with word finding. hx: this 27y/o rhf experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. she denied any associated dysphagia, diplopia, numbness or weakness of her extremities. she went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. she also awoke with a headache (ha) and mild neck stiffness. she took a shower and her ha and neck stiffness resolved. throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. that evening, she began to experience numbness and weakness in the lower right face. she felt like there was a &quot;rubber-band&quot; wrapped around her tongue. for 3 weeks prior to presentation, she experienced transient episodes of a &quot;boomerang&quot; shaped field cut in the left eye. the episodes were not associated with any other symptoms. one week prior to presentation, she went to a local er for menorrhagia. she had just resumed taking oral birth control pills one week prior to the er visit after having stopped their use for several months. local evaluation included an unremarkable carotid duplex scan. however, a hct with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. an mri brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. eeg reportedly showed diffuse slowing. crp was reportedly &quot;too high&quot; to calibrate. meds: ortho-novum 7-7-7 (started 2/3/96), and asa (started 2/20/96). pmh: 1)ventral hernia repair 10 years ago, 2)mild &quot;concussion&quot; suffered during a mva; without loss of consciousness, 5/93, 3) anxiety disorder, 4) one childbirth. fhx: she did not know her father and was not in contact with her mother. shx: lives with boyfriend. smokes one pack of cigarettes every three days and has done so for 10 years. consumes 6 bottles of beers, one day a week. unemployed and formerly worked at an herbicide plant. exam: bp150/79, hr77, rr22, 37.4c. ms: a&#038;o to person, place and time. speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. comprehension, naming and reading were intact. she was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. she had no difficulty with calculation. cn: vfftc, pupils 5/5 decreasing to 3/3. eom intact. no papilledema or hemorrhages seen on fundoscopy. no rapd or ino. there was right lower facial weakness. facial sensation was intact, bilaterally. the rest of the cn exam was unremarkable. motor: 5/5 strength throughout with normal muscle bulk and tone. sensory: no deficits. coord/station/gait: unremarkable. reflexes 2/2 throughout. plantar responses were flexor, bilaterally. gen exam: unremarkable. course: crp 1.2 (elevated), esr 10, rf 20, ana 1:40, anca &lt;1:40, tsh 2.0, ft4 1.73, anticardiolipin antibody igm 10.8gpl units (normal &lt;10.9), anticardiolipin antibody igg 14.8gpl (normal&lt;22.9), ssa and ssb were normal. urine beta-hcg pregnancy and drug screen were negative. ekg, cxr and ua were negative. mri brain, 2/21/96 revealed increased signal on t2 imaging in the periventricular white matter region of the right hemisphere. in addition, there were subtle t2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local mri can. in addition, special flair imaging showed increased signal in the right frontal region consistent with ischemia. she underwent cerebral angiography on 2/22/96. this revealed decreased flow and vessel narrowing the candelabra branches of the rmca supplying the right frontal lobe. these changes corresponded to the areas of ischemic changes seen on mri. there was also segmental narrowing of the caliber of the vessels in the circle of willis. there was a small aneurysm at the origin of the lpca. there was narrowing in the supraclinoid portion of the rica and the proximal m1 and a1 segments. the study was highly suggestive of vasculitis. 2/23/96, neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. neuropsychologic testing the same day revealed slight impairment of complex attention only. she was started on prednisone 60mg qd and tagamet 400mg qhs. on 2/26/96, she underwent a right frontal brain biopsy. pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. initial hct was unremarkable. an eeg was consistent with a focal lesion in the left hemisphere. however, a 2/28/96 mri brain scan revealed new increased signal on t2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. this was felt consistent with vasculitis. she began q2month cycles of cytoxan (1,575mg iv on 2/29/96. she became pregnant after her 4th cycle of cytoxan, despite warnings to the contrary. after extensive discussions with ob/gyn it was recommended she abort the pregnancy. she underwent neuropsychologic testing which revealed no significant cognitive deficits. she later agreed to the abortion. she has undergone 9 cycles of cytoxan ( one cycle every 2 months) as of 4/97. she had complained of one episode of paresthesias of the lue in 1/97. mri then showed no new signs ischemia."
+"preoperative diagnosis:  nausea and vomiting and upper abdominal pain. post procedure diagnosis:  normal upper endoscopy. operation:  esophagogastroduodenoscopy with antral biopsies for h. pylori x2 with biopsy forceps. anesthesia:  iv sedation 50 mg demerol, 8 mg of versed. procedure:  the patient was taken to the endoscopy suite.  after adequate iv sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  a bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  the first, second, and third portions of the duodenum were normal.  the scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for h. pylori.  the scope was retroflexed which showed a normal ge junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  the scope was withdrawn at the ge junction which was in a normal position with a normal transition zone.  the scope was then removed throughout the esophagus which was normal.  the patient tolerated the procedure well. the plan is to obtain a hida scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone."
+"diagnoses:1.  juvenile myoclonic epilepsy.2.  recent generalized tonic-clonic seizure. medications:1.  lamictal 250 mg b.i.d.2.  depo-provera. interim history:  the patient returns for followup.  since last consultation she has tolerated lamictal well, but she has had a recurrence of her myoclonic jerking.  she has not had a generalized seizure.  she is very concerned that this will occur.  most of the myoclonus is in the mornings.  recent eeg did show polyspike and slow wave complexes bilaterally, more prominent on the left.  she states that she has been very compliant with the medications and is getting a good amount of sleep.  she continues to drive. social history and review of systems are discussed above and documented on the chart. physical examination:  vital signs are normal.  pupils are equal and reactive to light.  extraocular movements are intact.  there is no nystagmus.  visual fields are full.  demeanor is normal.  facial sensation and symmetry is normal.  no myoclonic jerks noted during this examination.  no myoclonic jerks provoked by tapping on her upper extremity muscles.  negative orbit.  deep tendon reflexes are 2 and symmetric.  gait is normal.  tandem gait is normal.  romberg negative. impression and plan:  recurrence of early morning myoclonus despite high levels of lamictal.  she is tolerating the medication well and has not had a generalized tonic-clonic seizure.  she is concerned that this is a precursor for another generalized seizure.  she states that she is compliant with her medications and has had a normal sleep-wake cycle. looking back through her notes, she initially responded very well to keppra, but did have a breakthrough seizure on keppra.  this was thought secondary to severe insomnia when her baby was very young.  because she tolerated the medication well and it was at least partially affective, i have recommended adding keppra 500 mg b.i.d.  side effect profile of this medication was discussed with the patient. i will see in followup in three months."
+"<strong>report: </strong>this is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. the patient was reported to be cooperative and was awake throughout the recording. <strong>clinical note: </strong>this is a 51-year-old male, who is being evaluated for dizziness. spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 hz seen mainly from the posterior head region. intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region. eye opening caused a bilateral symmetrical block on the first run. in addition to the above description, movement of muscle and other artifacts are seen. on subsequent run, no additional findings were seen. during subsequent run, again no additional findings were seen. hyperventilation was omitted. photic stimulation was performed, but no clear-cut photic driving was seen. ekg was monitored during this recording and it showed normal sinus rhythm when monitored. <strong>impression: </strong>this record is essentially within normal limits. clinical correlation is recommended."
+"<strong>interpretation:</strong> 1. predominant rhythm is normal sinus rhythm. 2. no supraventricular arrhythmia. 3. frequent premature ventricular contractions. 4. trigemini and couplets. 5. no high-grade atrial ventricular block was noted. 6. diary was not kept. <strong>impression:</strong> frequent premature atrial contractions, couplets, and trigemini."
+"preoperative diagnosis: chronic abdominal pain and heme positive stool. postoperative diagnoses:1.  antral gastritis.2.  duodenal polyp. procedure performed:  esophagogastroduodenoscopy with photos and antral biopsy. anesthesia:  demerol and versed. description of procedure:  consent was obtained after all risks and benefits were described.  the patient was brought back into the endoscopy suite.  the aforementioned anesthesia was given.  once the patient was properly anesthetized, bite block was placed in the patient&#8217;s mouth.  then, the patient was given the aforementioned anesthesia.  once he was properly anesthetized, the endoscope was placed in the patient&#8217;s mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  the air was insufflated down.  the scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  the scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  the scope was pulled back into the stomach in order to flex upon itself and straightened out.  biopsies were taken for clo and histology of the antrum.  the scope was pulled back.  the junction was visualized.  no other masses or lesions were seen.  the scope was removed.  the patient tolerated the procedure well.  we will recommend the patient be on some type of a h2 blocker.  further recommendations to follow."
+"<strong>preoperative diagnosis: </strong>tracheal stenosis and metal stent complications. <strong>postoperative diagnosis: </strong>tracheal stenosis and metal stent complications. <strong>anesthesia: </strong>general endotracheal. <strong>endoscopic findings:</strong> 1. normal true vocal cords. 2. subglottic stenosis down to 5 mm with mature cicatrix. 3. tracheal granulation tissue growing through the stents at the midway point of the stents. 5. three metallic stents in place in the proximal trachea. 6. distance from the true vocal cords to the proximal stent, 2 cm. 7. distance from the proximal stent to the distal stent, 3.5 cm. 8. distance from the distal stent to the carina, 8 cm. 9. distal airway is clear. <strong>procedures:</strong> 1. rigid bronchoscopy with dilation. 2. excision of granulation tissue tumor. 3. application of mitomycin-c. 4. endobronchial ultrasound. <strong>technique in detail: </strong>after informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done. she had a dedo laryngoscope placed. her airways were inspected thoroughly with findings as described above. she was intermittently ventilated with an endotracheal tube placed through the dedo scope. her granulation tissue was biopsied and then removed with a microdebrider. her proximal trachea was dilated with a combination of balloon, bougie, and rigid scopes. she tolerated the procedure well, was extubated, and brought to the pacu."
+"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&#8217;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&#8217;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&#8217;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&#8217;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."
+"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 &quot;severe blurring&quot; 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."
+"reason for consultation:  new-onset seizure. history of present illness:  the patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  the typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  there have been no recent changes in her keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her. past medical history:  born at 36 weeks&#8217; gestation by c-section delivery at 8 pounds 3 ounces.  she does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue. past surgical history:  she has undergone no surgical procedures. family medical history:  there is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  there is no other significant neurological history on the paternal side of the family. social history:  currently lives with her mom, dad, and two siblings.  she is at home full time and does not attend day care. review of systems:  clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness. physical examination:vital signs:  weight was 15.6 kg.  she was afebrile.  remainder of her vital signs were stable and within normal ranges for her age as per the medical record.general:  she was awake, alert, and oriented.  she was in no acute distress, only slightly flustered when trying to place the eeg leads.heent:  showed normocephalic and atraumatic head.  her conjunctivae were nonicteric and sclerae were clear.  her eye movements were conjugate in nature.  her tongue and mucous membranes were moist.neck:  trachea appeared to be in the midline.chest:  clear to auscultation bilaterally without crackles, wheezes or rhonchi.cardiovascular:  showed a normal sinus rhythm without murmur.abdomen:  showed soft, nontender, and nondistended, with good bowel sounds.  there was no hepatomegaly or splenomegaly, or other masses noted on examination.extremities:  showed iv placement in the right upper extremity with appropriate restraints from the iv.  there was no evidence of clubbing, cyanosis or edema throughout.  she had no functional deformities in any of her peripheral limbs.neurological:  from neurological standpoint, her cranial nerves were grossly intact throughout.  her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  her overall resting tone was normal.  sensory examination was grossly intact to light touch throughout the upper and lower extremities.  reflexes were 1+ in bilateral patella.  toes were downgoing bilaterally.  coordination showed accurate striking ability and good rapid alternating movements.  gait examination was deferred at this time due to eeg lead placement. assessment:  a 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures. recommendations1.  for now, we will go ahead and try to capture eeg as long as she tolerates it; however, if she would require sedation, i would defer the eeg until further adjustments to seizure medications are made and we will see her response to these medications.2.  as per the above, i will increase her keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  if further spells are noted, we may increase upwards again to around 4.5 to 5 ml each day.3.  i do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her eeg findings.  eeg, hopefully, will be able to be reviewed first thing tomorrow morning; however, i would not delay discharge the patient to wait on the eeg results.  the patient has been discharged and we will contact the family as an outpatient.4.  the patient will need followup arrangement with me in 5 to 6 weeks&#8217; time, so we may recheck and see how she is doing and arrange for further followup then."
+"procedure performed:  egd with biopsy. indication:  mrs. abc is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  she was admitted because of recurrent nausea and vomiting, with displacement of the gej feeding tube.  a ct scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  the endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness. medications:  fentanyl 25 mcg, versed 2 mg, 2% lidocaine spray to the pharynx. instrument:  gif 160. procedure report:  informed consent was obtained from mrs. abc&#8217;s sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  consent was not obtained from mrs. morales due to her recent narcotic administration.  conscious sedation was achieved with the patient lying in the left lateral decubitus position.  the endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum. findings:1.  esophagus:  there was evidence of grade c esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  multiple biopsies were obtained from this region and placed in jar #1.2.  stomach:  small hiatal hernia was noted within the cardia of the stomach.  there was an indentation/scar from the placement of the previous peg tube and there was suture material noted within the body and antrum of the stomach.  the remainder of the stomach examination was normal.  there was no feeding tube remnant seen within the stomach.3.  duodenum:  this was normal. complications:  none. assessment:1.  grade c esophagitis seen within the distal, mid, and proximal esophagus.2.  small hiatal hernia.3.  evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach. plan:  followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube."
+"thank you very much for referring mr. y for pulmonary evaluation.  as you know, he is an 85-year-old man who has been referred for complaints of significant coughing and wheezing.  the patient was originally seen on 15/02/2008.  at that time he was complaining of the same symptoms as well as a recent cba.  the patient had a respiratory evaluation six months ago that was reported to be okay but he still complains of still some difficulty at the time of swallowing.  his followup today was done after the patient underwent initial swallowing evaluation.  he is still complaining of cough, wheezing, and congestion. 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."
+"cc: progressive visual loss. hx: 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. he continues to be anosmic, but has also recently noted decreased vision od. he denies any headaches, weakness, numbness, weight loss, or nasal discharge. meds: none. pmh: 1) diabetes mellitus dx 1 year ago. 2) benign prostatic hypertrophy, s/p turp. 3) right shoulder surgery (?djd). fhx: noncontributory. shx: denies history of tobacco/etoh/illicit drug use. exam: bp132/66 hr78 rr16 36.0c ms: a&#038;o to person, place, and time. no other specifics given in neurosurgery/otolaryngology/neuro-ophthalmology notes. cn: visual acuity has declined from 20/40 to 20/400, od; 20/30, os. no rapd. eom was full and smooth and without nystagmus. goldmann visual fields revealed a central scotoma and enlarged blind spot od and os (od worse) with a normal periphery. intraocular pressures were 15/14 (od/os). there was moderate pallor of the disc, od. facial sensation was decreased on the right side (v1 distribution). motor/sensory/coord/station/gait: were all unremarkable. reflexes: 2/2 and symmetric throughout. plantars were flexor, bilaterally. gen exam: unremarkable. course: mri brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both t1 and t2 weighted images arising from the planum sphenoidale and olfactory groove. the mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. the mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses. it also extends into the superomedial aspect of the right maxillary sinus. there is probable partial encasement of both internal carotid arteries just above the siphon. the optic nerves are difficult to visualize but there is also probable encasement of these structures as well. the mass enhances significantly with gadolinium contrast. these finds are consistent with meningioma. the patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. postoperatively, he lost visual acuity, os, but this gradually returned to baseline. his 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (od) and 20/80-2 (os). his visual fields continued to abnormal, but improved and stable when compared to 10/92. his anosmia never resolved."
+"exam:  ap abdomen and ultrasound of kidney. history:  ureteral stricture. ap abdomen  findings:  comparison is made to study from month dd, yyyy.  there is a left lower quadrant ostomy.  there are no dilated bowel loops suggesting obstruction.  there is a double-j right ureteral stent, which appears in place.  there are several pelvic calcifications, which are likely vascular.  no definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  overall findings are stable versus most recent exam. impression:  properly positioned double-j right ureteral stent.  no evidence for calcified renal or ureteral stones. ultrasound kidneys findings:  the right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  there is a right renal/ureteral stent identified.  there is no perinephric fluid collection. the left kidney demonstrates moderate-to-severe hydronephrosis.  no stone or solid masses seen.  the cortex is normal. the bladder is decompressed. impression:1.  left-sided hydronephrosis.2.  no visible renal or ureteral calculi.3.  right ureteral stent."
+"reason for consultation:  pneumothorax and subcutaneous emphysema. history of present illness:  the patient is a 48-year-old male who was initially seen in the emergency room on monday with complaints of scapular pain.  the patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice.  the patient was evaluated with a ct scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings.  the patient was admitted for observation. past surgical history:  hernia repair and tonsillectomy. allergies:  penicillin. medications:  please see chart. review of systems:  not contributory. physical examination:general:  well developed, well nourished, lying on hospital bed in minimal distress.heent:  normocephalic and atraumatic.  pupils are equal, round, and reactive to light.  extraocular muscles are intact.neck:  supple.  trachea is midline.chest:  clear to auscultation bilaterally.cardiovascular:  regular rate and rhythm.abdomen:  soft, nontender, and nondistended.  normoactive bowel sounds.extremities:  no clubbing, edema, or cyanosis.skin:  the patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday. diagnostic studies:  as above. impression:  the patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma.  these are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend. recommendations:  at this time, the ct surgery service has been consulted and has left recommendations.  the patient also is awaiting bronchoscopy per the pulmonary service.  at this time, there are no general surgery issues."
+"cc: orthostatic lightheadedness. hx: this 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. the dizziness worsened when moving into upright positions. in addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. he had lost 40 pounds over the past year and denied any recent fever, sob, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. he had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. he has a history of sinusitis. exam: bp 98/80 mmhg and pulse 64 bpm (supine); bp 70/palpable mmhg and pulse 84bpm (standing). rr 12, afebrile. appeared fatigued. cn: unremarkable. motor and sensory exam: unremarkable. coord: slowed but otherwise unremarkable movements. reflexes: 2/2 and symmetric throughout all 4 extremities. plantar responses were flexor, bilaterally. the rest of the neurologic and general physical exam was unremarkable. lab: na 121 meq/l, k 4.2 meq/l, cl 90 meq/l, co2 20meq/l, bun 12mg/dl, cr 1.0mg/dl, glucose 99mg/dl, esr 30mm/hr, cbc wnl with nl wbc differential, urinalysis: sg 1.016 and otherwise wnl, tsh 2.8 iu/ml, ft4 0.9ng/dl, urine osmolality 246 mosm/kg (low), urine na 35 meq/l, course: the patient was initially hydrated with iv normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. further laboratory studies revealed: aldosterone (serum)&lt;2ng/dl (low), 30 minute cortrosyn stimulation test: pre 6.9ug/dl (borderline low), post 18.5ug/dl (normal stimulation rise), prolactin 15.5ng/ml (no baseline given), fsh and lh were within normal limits for males. testosterone 33ng/dl (wnl). sinus xr series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. there was also an abnormal calcification seen in the middle of the sellar region. a left maxillary sinus opacity with air-fluid level was seen. goldman visual field testing was unremarkable. brain ct and mri revealed suprasellar mass most consistent with pituitary adenoma. he was treated with fludrocortisone 0.05 mg bid and within 24hrs, despite discontinuation of iv fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. his presumed pituitary adenoma continues to be managed with fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/tia)."
+"cc: difficulty with speech. hx: this 84 y/o rhf presented with sudden onset word finding and word phonation difficulties. she had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. these problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. carotid doppler studies showed 0-15% bica stenosis and a lica aneurysm (mentioned above). brain ct was unremarkable. she was placed on asa after the 2/92 event. in 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. hct at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. this was not felt to be a contusion; nevertheless, she was placed on dilantin seizure prophylaxis. her left arm was casted and she returned home. 5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. she was able to comprehend speech. this continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. there was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, ha, nausea, vomiting, or lightheadedness meds: asa , dph, tenormin, premarin, hctz pmh: 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)htn, 4)distal left internal carotid artery aneurysm. exam:  bp 168/70, pulse 82, rr 16, 35.8f ms:a &#038; o x 3, difficulty following commands, speech fluent, and without dysarthria. there were occasional phonemic paraphasic errors. cn: unremarkable. motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion. sensory: unremarkable. coordination: mild left finger-nose-finger dysynergia and dysmetria. gait: mildly unsteady tandem walk. station: no romberg sign. reflexes: slightly more brisk at the left patella than on the right. plantar responses were flexor bilaterally. the remainder of the neurologic exam and the general physical exam were unremarkable. labs: cbc wnl, gen screen wnl, , pt/ptt wnl, dph 26.2mcg/ml, cxr wnl, ekg: lbbb, hct revealed a left subdural hematoma. course: patient was taken to surgery and the subdural hematoma was evacuated. her mental status, language skills, improved dramatically. the dph dosage was adjusted appropriately."
+"procedure:  gastroscopy. preoperative diagnoses:  dysphagia, possible stricture. postoperative diagnosis:  gastroparesis. medication:  mac. description of procedure:  the olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  the hypopharynx was normal.  the esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  there was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  there was no sign of reflux esophagitis.  on entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  it had 2 to 3 mm diameter.  this was broken up using a scope into smaller pieces.  there was no retained gastric liquid.  the antrum appeared normal and the pylorus was patent.  the scope passed easily into the duodenum, which was normal through the second portion.  on withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  the scope was withdrawn.  the patient tolerated the procedure well and was sent to the recovery room. final diagnoses:1.  normal postoperative hernia repair.2.  retained gastric contents forming a partial bezoar, suggestive of gastroparesis.3.  otherwise normal upper endoscopy to the descending duodenum. recommendations:1.  continue proton pump inhibitors.2.  use reglan 10 mg three to four times a day."
+"procedure:  gastroscopy. preoperative diagnosis:  gastroesophageal reflux disease. postoperative diagnosis:  barrett esophagus. medications:  mac. procedure:  the olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum.  the preparation was excellent and all surfaces were well seen.  the hypopharynx appeared normal.  the esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted.  the ge junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors.  above the ge junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm.  this appears to be consistent with barrett esophagus.  multiple biopsies were taken from numerous areas in this region.  there was no active ulceration or inflammation and no stricture.  the hiatal hernia sac had normal mucosa except for one small erosion at the hiatus.  the gastric body had normal mucosa throughout.  numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance.  biopsies were taken from the antrum to rule out helicobacter pylori.  a retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions.  the scope was passed through the pylorus, which was patent and normal.  the mucosa throughout the duodenum in the first, second, and third portions was entirely normal.  the scope was withdrawn and the patient was sent to the recovery room.  he tolerated the procedure well. final diagnoses:1.  a short-segment barrett esophagus.2.  hiatal hernia.3.  incidental fundic gland polyps in the gastric body.4.  otherwise, normal upper endoscopy to the transverse duodenum. recommendations:1.  follow up biopsy report.2.  continue ppi therapy.3.  follow up with dr. x as needed.4.  surveillance endoscopy for barrett in 3 years (if pathology confirms this diagnosis)."
+"procedure:  colonoscopy. preoperative diagnoses:  change in bowel habits and rectal prolapse. postoperative diagnosis:  normal colonoscopy. procedure:  the olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  the preparation was poor, but mucosa was visible after lavage and suction.  small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  the mucosa was normal, was visualized.  in particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  biopsies were taken from the rectal wall to look for microscopic changes.  the anal sphincter was considerably relaxed, with no tone and a gaping opening.  the patient tolerated the procedure well and was sent to recovery room. final diagnosis:  normal colonic mucosa to the cecum.  no contraindications to consideration of a repair of the prolapse."
+"cc: left-sided weakness. hx: this 28y/o rhm was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. he denied foreign travel, iv drug abuse, homosexuality, recent dental work, or open wound. blood and urine cultures were positive for staphylococcus aureus, oxacillin sensitive. he was place on appropriate antibiotic therapy according to sensitivity.. a 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. later that day he developed left-sided weakness and severe dysarthria and aphasia. hct, on 7/3/95 revealed mild attenuated signal in the right hemisphere. on 7/4/95 he developed first degree av block, and was transferred to uihc. meds: nafcillin 2gm iv q4hrs, rifampin 600mg q12hrs, gentamicin 130mg q12hrs. pmh: 1) heart murmur dx age 5 years. fhx: unremarkable. shx: employed cook. denied etoh/tobacco/illicit drug use. exam: bp 123/54, hr 117, rr 16, 37.0c ms: somnolent and arousable only by shaking and repetitive verbal commands. he could follow simple commands only. he nodded appropriately to questioning most of the time. dysarthric speech with sparse verbal output. cn: pupils 3/3 decreasing to 2/2 on exposure to light. conjugate gaze preference toward the right. right hemianopia by visual threat testing. optic discs flat and no retinal hemorrhages or roth spots were seen. left lower facial weakness. tongue deviated to the left. weak gag response, bilaterally. weak left corneal response. motor: dense left flaccid hemiplegia. sensory: less responsive to pp on left. coord: unable to test. station and gait: not tested. reflexes: 2/3 throughout (more brisk on the left side). left ankle clonus and a left babinski sign were present. gen exam: holosystolic murmur heard throughout the precordium. janeway lesions were present in the feet and hands. no osler&#8217;s nodes were seen. course: 7/6/95, hct showed a large rmca stroke with mass shift. his neurologic exam worsened and he was intubated, hyperventilated, and given iv mannitol. he then underwent emergent left craniectomy and duraplasty. he tolerated the procedure well and his brain was allowed to swell. he then underwent mitral valve replacement on 7/11/95 with a st. judes valve. his post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. he required temporary peg placement for feeding. the 7/27/95, 8/6/95 and 10/18/96 hct scans show the chronologic neuroradiologic documentation of a large rmca stroke. his 10/18/96 neurosurgery clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. his proximal lle strength was rated at a 4. his lue was plegic. he had a seizure 6 days prior to his 10/18/96 evaluation. this began as a jacksonian march of shaking in the lue; then involved the lle. there was no loc or tongue-biting. he did have urinary incontinence. he was placed on dph. his speech was dysarthric but fluent. he appeared bright, alert and oriented in all spheres."
+"cc: headache. hx: 63 y/o rhf first seen by neurology on 9/14/71 for complaint of episodic vertigo. during that evaluation she described a several year history of &quot;migraine&quot; headaches. she experienced her first episode of vertigo in 1969. the vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. the vertigo had not been consistently associated with positional change and could last hours to days. on 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity ad. she complained of associated tinnitus which she described as a &quot;whistle.&quot; in addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). the symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. she was seen 9/14/71, in neurology, and admitted for evaluation. her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. cerebral angiogram revealed an inoperable 7 x 6cm avm in the right parietal region. the avm was primarily fed by the right mca. otolaryngologic evaluation concluded that she probably also suffered from meniere&#8217;s disease. on 10/14/74 she underwent a 21 day admission for sah secondary to right parietal avm. on 11/23/91 she was admitted for left sided weakness (lue &gt; lle), headache, and transient visual change. neurological exam confirmed left sided weakness, and dysesthesia of the lue only. brain ct confirmed a 3 x 4 cm left parietal hemorrhage. she underwent unsuccessful embolization. neuroradiology had planned to do 3 separate embolizations, but during the first, via the left mca, they were unable to cannulate many of the avm vessels and abandoned the procedure. she recovered with residual left hemisensory loss. in 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention. in 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the barrows neurological institute in phoenix, az."
+"history of present illness:  the patient is a 68-year-old man who returns for recheck.  he has a history of ischemic cardiac disease, he did see dr. xyz in february 2004 and had a thallium treadmill test.  he did walk for 8 minutes.  the scan showed some mild inferior wall scar and ejection fraction was well preserved.  he has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema. past medical history/surgeries/hospitalizations:  he had tonsillectomy at the age of 8.  he was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  he did have lima to the lad and had three saphenous vein grafts performed otherwise. medications:  kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin e 400 units daily, and citrucel one daily. allergies:  none known. family history:  father died at the age of 84.  he had a prior history of cancer of the lung and ischemic cardiac disease.  mother died in her 80s from congestive heart failure.  he has two brothers and six sisters living who remain in good health. personal history:  quit smoking in 1996.  he occasionally drinks alcoholic beverages. review of systems:endocrine:  he has hypercholesterolemia treated with diet and medication.  he reports that he did lose 10 pounds this year.neurologic:  denies any tia symptoms.genitourinary:  he has occasional nocturia.  denies any difficulty emptying his bladder.gastrointestinal:  he has a history of asymptomatic cholelithiasis. physical examination:vital signs:  weight:  225 pounds.  blood pressure:  130/82.  pulse:  83.  temperature:  96.4 degrees.general appearance:  he is a middle-aged man who is not in any acute distress.heent:  mouth:  the posterior pharynx is clear.neck:  without adenopathy or thyromegaly.chest:  lungs are resonant to percussion.  auscultation reveals normal breath sounds.heart:  normal s1, s2, without gallops or rubs.abdomen:  without tenderness or masses.extremities:  without edema. impression/plan:1.  ischemic cardiac disease.  this remains stable.  he will continue on the same medication.  he reports he has had some laboratory studies today.2.  hypercholesterolemia.  he will continue on the same medication.3.  facial tic.  we also discussed having difficulty with the facial tic at the left orbital region.  this occurs mainly when he is under stress.  he has apparently had numerous studies in the past and has seen several doctors in wichita about this.  at one time was being considered for some type of operation.  his description, however, suggests that they were considering an operation for tic douloureux.  he does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  repeat neurology evaluation was advised.  he will be scheduled to see dr. xyz in newton on 09/15/2004.4.  immunization.  addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  we will have this discussed with him further when his laboratory results are back."
+"preoperative diagnosis:  acute appendicitis. postoperative diagnosis:  acute suppurative appendicitis. procedure performed:  laparoscopic appendectomy. anesthesia:  general endotracheal and marcaine 0.25% local. indications:  this 29-year-old female presents to abcd general hospital emergency department on 08/30/2003 with history of acute abdominal pain.  on evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  however, the patient with additional history of loose stools for several days prior to event.  therefore, a cat scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  there was no evidence of colitis on the cat scan.  with this in mind and the patient&#8217;s continued pain at present, the patient was explained the risks and benefits of appendectomy.  she agreed to procedure and informed consent was obtained. gross findings:  the appendix was removed without difficulty with laparoscopic approach.  the appendix itself noted to have a significant inflammation about it.  there was no evidence of perforation of the appendix. procedure details:  the patient was placed in supine position.  after appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  through this incision, a veress needle was utilized to create a co2 pneumoperitoneum of 15 mmhg.  the veress needle was then removed.  a 10 mm trocar was then introduced through this incision into the abdomen.  a video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  photodocumentation was obtained. a 5 mm port was then placed in the right upper quadrant.  this was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  through this port, the dissector was utilized to create a small window in the mesoappendix.  next, an endogia with gi staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  two 6 x-loupe wires with endogia were utilized in this prior portion of the procedure.  next, an endocatch was placed through the 12 mm port and the appendix was placed within it.  the appendix was then removed from the 12 mm port site and taken off the surgical site.  the 12 mm port was then placed back into the abdomen and co2 pneumoperitoneum was recreated.  the base of the appendix was reevaluated and noted to be hemostatic.  aspiration of warm saline irrigant then done and noted to be clear.  there was a small adhesion appreciated in the region of the surgical site.  this was taken down with blunt dissection without difficulty.  there was no evidence of other areas of disease.  upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  the instruments were removed from the patient and the port sites were then taken off under direct visualization.  the co2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 vicryl ligature x2.  marcaine 0.25% was then utilized in all three incision sites and #4-0 vicryl suture was used to approximate the skin and all three incision sites.  steri-strips and sterile dressings were applied.  the patient tolerated the procedure well and taken to postoperative care unit in stable condition and monitored under general medical floor on iv antibiotics, pain medications, and return to diet."
+"chief complaint:  abdominal pain. history of present illness:  the patient is a 71-year-old female patient of dr. x. the patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  she was seen 3 to 4 days ago at abc er and underwent evaluation and discharged and had a ct scan at that time and she was told it was &quot;normal.&quot;  she was given oral antibiotics of cipro and flagyl.  she has had no nausea and vomiting, but has had persistent associated anorexia.  she is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  she denies any bright red blood per rectum and no history of recent melena.  her last colonoscopy was approximately 5 years ago with dr. y. she has had no definite fevers or chills and no history of jaundice.  the patient denies any significant recent weight loss. past medical history:  significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on premarin hormone replacement. past surgical history:  significant for cholecystectomy, appendectomy, and hysterectomy.  she has a long history of known grade 4 bladder prolapse and she has been seen in the past by dr. chip winkel, i believe that he has not been re-consulted. allergies:  she is allergic or sensitive to macrodantin. social history:  she does not drink or smoke. review of systems:  otherwise negative for any recent febrile illnesses, chest pains or shortness of breath. physical examination:general:  the patient is an elderly thin white female, very pleasant, in no acute distress.vital signs:  her temperature is 98.8 and vital signs are all stable, within normal limits.heent:  head is grossly atraumatic and normocephalic.  sclerae are anicteric.  the conjunctivae are non-injected.neck:  supple.chest:  clear.heart:  regular rate and rhythm.abdomen:  generally nondistended and soft.  she is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  there is no cva or flank tenderness, although some very minimal left flank tenderness.pelvic:  currently deferred, but has history of grade 4 urinary bladder prolapse.extremities:  grossly and neurovascularly intact. laboratory values:  white blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  alkaline phosphatase elevated at 184.  liver function tests otherwise normal.  electrolytes normal.  glucose 134, bun 4, and creatinine 0.7. diagnostic studies:  ekg shows normal sinus rhythm. impression and plan:  a 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  currently is a nonacute abdomen.  the working diagnosis would be sigmoid diverticulitis.  she does have a history in the distant past of sigmoid diverticulitis.  i would recommend a repeat stat ct scan of the abdomen and pelvis and keep the patient nothing by mouth.  the patient was seen 5 years ago by dr. y in colorectal surgery.  we will consult her also for evaluation.  the patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  the case was discussed with the patient&#8217;s primary care physician, dr. x. again, currently there is no indication for acute surgical intervention on today&#8217;s date, although the patient will need close observation and further diagnostic workup."
+"history of present illness:  this is a 53-year-old widowed woman, she lives at abc hotel.  she presented with a complaint of chest pain, evaluations revealed severe aortic stenosis.  she has been refusing cardiac catheter and she may well need aortic valve replacement.  she states that she does not want heart surgery or valve replacement.  she has a history of bipolar disorder and has been diagnosed at times with schizophrenia.  she is on depakote 500 mg three times a day and geodon 80 mg twice a day.  the patient receives mental health care through the xyz health system and there is a psychiatrist who makes rounds at the abc hotel.  she denies hallucinations, psychosis, paranoia, and suicidal ideation at this time.  states that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks.  the patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the xyz county jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days. the patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care. past and developmental history:  she was born in xyz.  she is a high-school graduate from abcd high school.  she did have an abusive childhood.  she is married four times.  she notes she developed depression when a number of her children died. physical examination:  general:  this is an obese woman in bed.  she is somewhat restless and moving during the interview.vital signs:  temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 l of oxygen.psychiatry:  speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level.  there is no overt thought disorder.  she does not appear psychotic.  she is not suicidal on formal testing.  she gives the date as sunday, 05/19/2007 when it is the 20th and 207 when it is 2007.  she is oriented to place.  she can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits.  she had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, &quot;december, november, september, october, june, july, august, september,&quot; but recognizes this was not right and then said, &quot;march, april, may.&quot;  she is able to name objects appropriately. laboratory data:  chest x-ray showing no acute changes.  carotid duplex shows no stenosis.  electrolytes and liver function tests are normal.  tsh normal.  hematocrit 31%.  triglycerides 152. diagnoses:  1.  bipolar disorder, apparently stable on medications.2.  mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.3.  aortic stenosis.4.  sleep apnea.5.  obesity.6.  anemia.7.  gastroesophageal reflux disease. recommendations:  it is my impression at present that the patient retains ability to make decisions on her own behalf.  given this lady&#8217;s underlying mental problems, i would recommend that her treating physicians discuss her circumstances with physicians who round on her at the abc hotel.  while she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her.  she clearly at this time wants to leave this hospital; she normally gets her care through xyz health.  again, in summary, i would consider her to retain the ability to make decisions on her own behalf. please feel free to contact me at digital pager if additional information is needed."
+"history of present illness:  the patient is a 69-year-old single caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, gerd, and dyslipidemia who presents to the emergency room with the complaint of &quot;manic&quot; symptoms due to recent medication adjustments.  the patient had been admitted to st. luke&#8217;s hospital on month dd, yyyy for altered mental status and at that time, the medical team discontinued zyprexa and lithium.  in the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  she also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  she was admitted voluntarily to the inpatient unit and medications were not restarted for her.  on the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  she reports that she would like to speak with dr. a, the neurologist who saw her at st. luke&#8217;s, because she &quot;trust him.&quot;  the patient is somewhat reluctant to answer questions stating that she has answered enough of people&#8217;s questions; however, she is talkative and reports that she feels as though she needs a sedative.  the patient reports that she is originally from brooklyn, new york, and she moved down to houston about a year ago to be with her daughter.  she also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  the patient also complains that her daughter is &quot;trying to tell me what medications to take.&quot;  the patient sees dr. b in the woodlands for outpatient care. past psychiatric history:  per chart.  the patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  she has been stable on lithium and zyprexa according to her daughter and was recently taken off those medications, changed to seroquel, and the daughter reports that she has decompensated since then.  it is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has. medications: 1.  seroquel 100 mg, 1 p.o. b.i.d.2.  risperdal 1 mg tab, 1 p.o. t.i.d.3.  actos 30 mg, 1 p.o. daily.4.  lipitor 10 mg, 1 p.o. at bedtime.5.  gabapentin 100 mg, 1 p.o. b.i.d.6.  glimepiride 2 mg, 1 p.o. b.i.d.7.  levothyroxine 25 mcg, 1 p.o. q.a.m.8.  protonix 40 mg, 1 p.o. daily. allergies:  no known drug allergies. family history:  per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia. social history:  the patient is from brooklyn, new york and moved to houston approximately one year ago.  she lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  she has been married once, but her spouse left her when her three children were young.  her children are ages 47, 49, and 51.  she had one year of college, and she currently is retired after working in new york public schools for 20 or more years.  she reports that her spouse was physically abusive to her.  she reports occasional alcohol use and quit smoking 11 years ago. mental status exam:  general:  the patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.behavior:  the patient is singing loudly and joking with interviewers.  she is pleasant, but non-cooperative with interview.speech:  increased volume, rate, and tone.  normal in flexion and articulation.  motor:  agitated.mood:  okay.affect:  elevated and congruent.thought processes:  tangential and logical at times.thought contents:  denies suicidal or homicidal ideation.  denies auditory or visual hallucination.  positive grandiose delusions and positive paranoid delusions.insight:  poor to fair.judgment:  impaired.  the patient is alert and oriented to person, place, date, year, but not day of the week. laboratory data:  sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, bun 23, creatinine 1.1, and calcium 10.6.  acetaminophen level 3.3 and salicylate level less than 0.14.  wbc 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  urinalysis within normal limits. physical examination:general:  alert and oriented, in no acute distress.vital signs:  blood pressure 152/92, heart rate 81, and temperature 97.2.heent:  normocephalic and atraumatic.  perrla.  eomi.  mmm.  op clear.neck:  supple.  no lad, no jvd, and no bruits.chest:  clear to auscultation bilaterally.cardiovascular:  regular rate and rhythm.  s1 and s2 heard.  no murmurs, rubs, or gallops.abdomen:  obese, soft, nontender, and nondistended.  positive bowel sounds x4.extremities:  no cyanosis, clubbing, or edema. assessment:  this is a 69-year-old caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and gerd who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to st. luke&#8217;s hospital during which time the patient was taken off her usual medications of lithium and zyprexa.  the patient is manic and disinhibited and is unable to give a sufficient interview at this time. axis i:  schizoaffective disorder.axis ii:  deferred.axis iii:  diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.axis iv:  family strife and recent relocation.axis v:  gaf equals 25. plan:  the patient was admitted voluntarily to the abcd hospital inpatient psychiatric unit under dr. c&#8217;s care.  medications resumed include zyprexa, actos, levothyroxine, lipitor, protonix, glimepiride, and folate.  we will order an ekg, and we will monitor the patient and make further adjustments to her medications as necessary."
+"preoperative diagnosis:  blood loss anemia. postoperative diagnoses:1.  normal colon with no evidence of bleeding.2.  hiatal hernia.3.  fundal gastritis with polyps.4.  antral mass. anesthesia:  conscious sedation with demerol and versed. specimen:  antrum and fundal polyps. history:  the patient is a 66-year-old african-american female who presented to abcd hospital with mental status changes.  she has been anemic as well with no gross evidence of blood loss.  she has had a decreased appetite with weight loss greater than 20 lb over the past few months.  after discussion with the patient and her daughter, she was scheduled for egd and colonoscopy for evaluation. procedure:  after informed consent was obtained, the patient was brought to the endoscopy suite.  she was placed in the left lateral position and was given iv demerol and versed for sedation.  when adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  the colonoscope was inserted into the rectum and air was insufflated.  the scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  there were no polyps, masses, diverticuli, or areas of inflammation.  the scope was then slowly withdrawn carefully examining all walls.  air was aspirated.  once in the rectum, the scope was retroflexed.  there was no evidence of perianal disease.  no source of the anemia was identified. attention was then taken for performing an egd.  the gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  the esophagus was easily intubated and traversed.  there were no abnormalities of the esophagus.  the stomach was entered and was insufflated.  the scope was coursed along the greater curvature towards the antrum.  adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  it was not clear if this represents a healing ulcer or neoplasm.  several biopsies were taken.  the mass was soft.  the pylorus was then entered.  the duodenal bulb and sweep were examined.  there was no evidence of mass, ulceration, or bleeding.  the scope was then brought back into the antrum and was retroflexed.  in the fundus and body, there was evidence of streaking and inflammation.  there were also several small sessile polyps, which were removed with biopsy forceps.  biopsy was also taken for clo.  a hiatal hernia was present as well.  air was aspirated.  the scope was slowly withdrawn.  the ge junction was unremarkable.  the scope was fully withdrawn.  the patient tolerated the procedure well and was transferred to recovery room in stable condition.  she will undergo a cat scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  we will await the biopsy reports and further recommendations will follow."
+"spirometry:  spirometry reveals the fvc to be adequate. fev1 is also normal at 98% predicted and fvc is 90.5% predicted.  fef25-75% is also within normal limits at 110% predicted.  fev1/fvc ratio is within normal limits at 108% predicted. after the use of bronchodilator, there is some improvement with 10%.  mvv is within normal limits. lung volumes:  shows total lung capacity to be normal.  rv as well as rv/tlc ratio they are within normal limits. diffusion capacity:  shows that after correction for alveolar ventilation, is also normal.oxygen saturation on room air:  98%. final interpretation:  pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease.  there is some improvement after the use bronchodilator.  diffusion capacity is within normal limits.  oxygen saturation on room air is also normal.  clinical correlation will be necessary in this case."
+"procedures1.  left heart catheterization.2.  coronary angiography.3.  left ventriculogram. preprocedure diagnosis:  atypical chest pain. postprocedure diagnoses1.  no angiographic evidence of coronary artery disease.2.  normal left ventricular systolic function.3.  normal left ventricular end diastolic pressure. indication:  the patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with aicd placement, and hepatitis c. the patient was admitted for atypical chest pain and scheduled for cardiac catheterization. procedure in detail:  after informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  he was prepped and draped in the usual sterile manner.  the right inguinal area was anesthetized with 2% xylocaine.  a 4-french sheath was inserted into the right femoral artery using the modified seldinger technique.  jl4 and 3drc catheters were used to cannulate the left and right coronary arteries respectively.  coronary angiographies were performed.  these catheters were removed and exchanged for a 4-french pigtail catheter, which was positioned into the left ventricle.  left ventriculography was performed.  the patient tolerated the procedure well.  at the end of the procedure, all catheters and sheaths were removed.  the patient was then transferred to telemetry in a stable condition. hemodynamic data:  hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmhg and the lv 100/0 with lvedp of 10 mmhg. aortic valve:  there is no significant gradient across this valve noted. lv gram:  a 10 ml of contrast were delivered for 3 seconds for a total of 30 ml.  ejection fraction was calculated to be 69%.  there were no wall motion abnormalities noted. angiogramleft main coronary artery:  left main coronary artery is a moderate-caliber vessel free of disease and trifurcates. lad:  lad is a long, tortuous vessel which wraps around the apex.  the lad is small in caliber.  in addition, there is a long bifurcating small-caliber diagonal branch noted.  lad and its branches are free of disease. ramus intermedius:  ramus intermedius is a long small-caliber vessel free of disease. lcx:  lcx is a nondominant small-caliber vessel with long bifurcating small-caliber distal om branch.  lcx and its branches are free of disease. rca:  rca is a dominant small-caliber vessel with long small-caliber pda branch.  rca and its branches are free of disease. impression1.  no angiographic evidence of coronary artery disease.2.  normal left ventricular systolic function.3.  normal left ventricular end diastolic pressure. recommendation:  recommend to look for alternative causes of chest pain."
+"history of present illness:  a 67-year-old male with copd and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  he was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding copd.  unfortunately over the past few months he has returned to pipe smoking.  at the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms. past medical history:  status post artificial aortic valve implantation in summer of 2002 and is on chronic coumadin therapy.  copd as described above, history of hypertension, and history of elevated cholesterol. physical examination:  heart tones regular with an easily audible mechanical click.  breath sounds are greatly diminished with rales and rhonchi over all lung fields. laboratory studies:  sodium 139, potassium 4.5, bun 42, and creatinine 1.7.  hemoglobin 10.7 and hematocrit 31.7. hospital course:  he was started on intravenous antibiotics, vigorous respiratory therapy, intravenous solu-medrol.  the patient improved on this regimen.  chest x-ray did not show any chf.  the cortisone was tapered.  the patient&#8217;s oxygenation improved and he was able to be discharged home. discharge diagnoses:  chronic obstructive pulmonary disease and acute asthmatic bronchitis. complications:  none. discharge condition:  guarded. discharge plan:  prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  to follow up with me in the office in 4-5 days."
+"procedure:  esophagogastroduodenoscopy with biopsy. reason for procedure:  the child with history of irritability and diarrhea with gastroesophageal reflux.  rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  he has been on prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability. consent history and physical examinations were performed.  the procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  opportunity for questions was provided and informed consent was obtained. medications:  general anesthesia. instrument:  olympus gif-xq 160. complications:  none. estimated blood loss:  less than 5 ml. findings:  with the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  the proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  a z-line was identified within the lower esophageal sphincter.  the endoscope was advanced into the stomach, which was distended with excess air.  the rugal folds flattened completely.  the gastric mucosa was entirely normal.  no hiatal hernia was seen and the pyloric valve appeared normal.  the endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  ampule of vater was identified and found to be normal.  biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  additional two antral biopsies were obtained for clo testing.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated the procedure well.  the patient was taken to recovery room in satisfactory condition. impression:  normal esophagus, stomach, and duodenum. plan:  histologic evaluation and clo testing.  continue prevacid 7.5 mg p.o. b.i.d.  i will contact the parents next week with biopsy results and further management plans will be discussed at that time."
+"history of present illness:  this is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  the patient also has a positive history of smoking in the past.  at the present time, he is admitted for continuedmanagement of respiratory depression with other medical complications.  the patient was treated for multiple problems at jefferson hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  in addition, he also developed cardiac complications including atrial fibrillation.  the patient was evaluated by the cardiologist as well as the pulmonary service and urology.  he had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  he subsequently underwent cardiac arrest and he was resuscitated at that time.  he was intubated and placed on mechanical ventilatory support.  subsequent weaning was unsuccessful.  he then had a tracheostomy placed. current medications:1.  albuterol.2.  pacerone.3.  theophylline4.  lovenox.5.  atrovent.6.  insulin.7.  lantus.8.  zestril.9.  magnesium oxide.10.  lopressor.11.  zegerid.12.  tylenol as needed. allergies:  penicillin. past medical history:1.  history of coal miner&#8217;s disease.2.  history of copd.3.  history of atrial fibrillation.4.  history of coronary artery disease.5.  history of coronary artery stent placement.6.  history of gastric obstruction.7.  history of prostate cancer.8.  history of chronic diarrhea.9.  history of pernicious anemia.10.  history of radiation proctitis.11.  history of anxiety.12.  history of ureteral stone.13.  history of hydronephrosis. social history:  the patient had been previously a smoker.  no other could be obtained because of tracheostomy presently. family history:  noncontributory to the present condition and review of his previous charts. systems review:  the patient currently is agitated.  rapidly moving his upper extremities.  no other history regarding his systems could be elicited from the patient. physical exam:general:  the patient is currently agitated with some level of distress.  he has rapid respiratory rate.  he is responsive to verbal commands by looking at the eyes.vital signs:  as per the monitors are stable.extremities:  inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage ii especially over the dorsum of the hands and forearm areas.  there is also edema of the forearm extending up to the mid upper arm area.  palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  there is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area. impression:1.  ulceration of bilateral upper extremities.2.  cellulitis of upper extremities.3.  lymphedema of upper extremities.4.  other noninfectious disorders of lymphatic channels.5.  ventilatory-dependent respiratory failure.6.  history of coal worker&#8217;s pneumoconiosis with fibrosis.7.  history of coronary artery disease.8.  history of paroxysmal atrial fibrillation.9.  history of paraesophageal hernia repair.10.  history of prostate cancer status post radiation therapy.11.  history of chronic obstructive pulmonary disease.12.  history of ureteral stone.13.  history of hydronephrosis. plan:  at this point, the patient&#8217;s skin tears and ulcerations of the upper extremities will be dressed with adaptic and soft kerlix bandages to be changed daily.  the patient will also need hydration of the upper extremities with lac-hydrin as needed.  with respect to the edema management, we will continue to monitor the status of the fibrosis and we will make a decision about compression wrap if needed.  to this extent, we will involve wound care team to monitor the skin tears and the ulceration."
+"history of present illness:  the patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  she also has a significant history of chronic renal insufficiency and severe copd.  the patient and her husband live in abc but they have family in xyz.  she came to our office today as she is in the area visiting her family.  she complains of having shortness of breath for the past month that has been increasingly getting worse.  she developed a frequent nonproductive cough about 2 weeks ago.  she has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  she has also gained about 15 pounds in the past few months and has significant peripheral edema.  in the office, she is obviously dyspnea and speaking in 2 to 3 word sentences. past medical history:  coronary artery disease, anemia secondary to chronic renal insufficiency, stage iv chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, copd, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia. past surgical history:  status post pacemaker implantation, status post cabg x4 in 1999 and status post cabg x2 in 2003, status post pca stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies. social history:  the patient is married.  lives with her husband.  they are retired from abc. medications:1.  plavix 75 mg p.o. daily.2.  aspirin 81 mg p.o. daily.3.  isosorbide mononitrate 60 mg p.o. daily.4.  colace 100 mg p.o. b.i.d.5.  atenolol 50 mg p.o. daily.6.  lantus insulin 15 units subcutaneously every evening.7.  protonix 40 mg p.o. daily.8.  furosemide 40 mg p.o. daily.9.  norvasc 5 mg p.o. daily. allergies:  she is allergic to heparin agents, which cause heparin-induced thrombocytopenia. review of systemsconstitutional:  positive for generalized fatigue and malaise.head and neck:  negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.cardiovascular:  positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.respiratory:  positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  negative for wheezing.abdomen:  negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.genitourinary:  negative for dysuria, polyuria, hematuria, or incontinence.musculoskeletal:  negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.skin:  negative for rashes, petechiae, and hair or nail changes.  positive for easy bruising on forearms.neurologic:  negative for paralysis, paresthesias, dysphagia, or dysarthria.psychiatric:  negative for depression, anxiety, or mood swings. all other systems reviewed are negative. physical examinationvital signs:  her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  her height is 63 inches.  she is weighs 195 pounds and her bmi is 34.6.constitutional:  a 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.heent:  eyes:  pupils are reactive.  sclera is nonicteric.  ears, nose, mouth, and throat.neck:  supple.  no lymphadenopathy.  no thyromegaly.  swallow is intact.cardiovascular:  positive jvd at 45 degrees.  heart tones are distant.  s1 and s2.  no murmurs.extremities:  have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  femoral pulses are weakly palpable.  posterior tibial pulses are not palpable.  capillary refill is somewhat sluggish.respiratory:  breath sounds are clear with some bilateral basilar diminishment.  no rales and no wheezing.  speaking in 2 to 3 word sentences.  diaphragmatic excursions are limited.  ap diameter is expanded.abdomen:  soft and nontender.  active bowel sounds x4 quadrants.  no hepatosplenomegaly.  no masses are appreciated.genitourinary:  deferred.musculoskeletal:  adequate range of motion along with extremities.skin:  warm and dry.  no lesions or ulcerations are noted.neurologic:  alert and oriented x3.  head is normocephalic and atraumatic.  no focal, motor, or sensory deficits.psychiatric:  normal affect. impression1.  coronary artery disease.2.  stage iv chronic renal insufficiency.3.  acute symptoms of congestive heart failure with 15 pound weight gain.4.  dyspnea on exertion and dyspnea at rest.5.  indigestion x2 weeks, which could be anginal equivalent. plan1.  routine labs to rule out acute myocardial infarction.2.  serial ekgs.3.  echocardiogram.4.  consider nuclear stress testing."
+"gross description:a.  received fresh labeled with patient&#8217;s name, designated &#8216;right upper lobe wedge&#8217;, is an8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line.  there is a 0.8 x0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.b.  received fresh, labeled with patient&#8217;s name, designated &quot;lymph node&#8217;, is a 1.7 cm possible lymph node with anthracotic pigment.c.  received fresh labeled with patient&#8217;s name, designated &#8216;right upper lobe&#8217;, is a 16.0 x14.5 x 6.0 cm lobe of lung.  the lung is inflated with formalin.  there is a 12.0 cm staple line on the lateral surface, inked blue.  there is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line.  the overlying pleura is puckered.d.  received fresh, labeled with patient&#8217;s name, designated &#8217;4 lymph nodes&#8217;, is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.e.  received fresh, labeled with patient&#8217;s name, designated &#8216;subcarinal lymph node&#8217;, is a2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment . final diagnosis:a.  right upper lobe wedge lung biopsy:  poorly differentiated non-small cell carcinoma.  tumor size:  0.8 cm.  arterial (large vessel) invasion:  not seen.  small vessel (lymphatic) invasion:  not seen.  pleural invasion:  not identified.  margins of excision:  negative for malignancy.b.  biopsy, 10r lymph node:  anthracotically pigmented lymphoid tissue, negative for malignancy.c.  right upper lobe, lung:  moderately differentiated non-small cell carcinoma(adenocarcinoma).  tumor size:  1.3 cm.  arterial (large vessel) invasion:  present.  small vessel (lymphatic) invasion:  not seen.  pleural invasion:  not identified.  margins of excision:  negative for malignancy.d.  biopsy, 4r lymph nodes:  lymphoid tissue, negative for malignancy.e.  biopsy, subcarinal lymph node:  lymphoid tissue, negative for malignancy. comments:  pathologic examination reveals two separate tumors in the right upper lobe.  they appear histologically distinct, suggesting they are separate primary tumors (pt1).  the right upper lobe wedge biopsy (part a) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy.  the right upper lobe carcinoma identified in the resection (part c) is a moderately differentiated adenocarcinoma with obvious gland formation."
+"re:  sample patient dear sample doctor: thank you for referring mr. sample patient for cardiac evaluation.  this is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  he has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or pnd.  he is known to have a mother with coronary heart disease.  he has never been a smoker.  he has never had a syncopal episode, mi, or cva.  he had his gallbladder removed.  no bleeding tendencies.  no history of dvt or pulmonary embolism.  the patient is retired, rarely consumes alcohol and consumes coffee moderately.  he apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  he is allergic to codeine and aspirin (angioedema). physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  his heart rate was 98 beats per minute and regular.  his blood pressure was 140/80 mmhg in the right arm in a sitting position and 150/80 mmhg in a standing position.  he is in no distress.  venous pressure is normal.  carotid pulsations are normal without bruits.  the lungs are clear.  cardiac exam was normal.  the abdomen was obese and organomegaly was not palpated.  there were no pulsatile masses or bruits.  the femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  there was no peripheral edema.   he had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  renal function was normal.  his lipid profile showed a slight increase in triglycerides with normal total cholesterol and hdl and an acceptable range of ldl.  his sodium was a little bit increased.  his a1c hemoglobin was increased.  he had a spirometry, which was reported as normal.   he had a resting electrocardiogram on december 20, 2002, which was also normal.  he had a treadmill cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  there were no symptoms or ischemia by ekg.  there was some suggestion of inferior wall ischemia with normal wall motion by cardiolite imaging. in summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  i am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  he denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.   in view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  i explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  he also should start aggressively losing weight.  i have requested additional testing today, which will include an apolipoprotein b, lpa lipoprotein, as well as homocystine, and cardio crp to further assess his risk of atherosclerosis.   in terms of medication, i have changed his verapamil for a long acting beta-blocker, he should continue on an ace inhibitor and his plavix.  the patient is allergic to aspirin.  i also will probably start him on a statin, if any of the studies that i have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which i believe he should.  this, however, i will leave entirely up to you to decide.  if indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular. i do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms. if you have any further questions, please do not hesitate to let me know. thank you once again for this kind referral. sincerely, sample doctor, m.d."
+"exam:  echocardiogram. interpretation:  echocardiogram was performed including 2-d and m-mode imaging, doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in m-mode.  cardiac chamber dimensions, left atrial enlargement 4.4 cm.  left ventricle, right ventricle, and right atrium are grossly normal.  lv wall thickness and wall motion appeared normal.  lv ejection fraction is estimated at 65%.  aortic root and cardiac valves appeared normal.  no evidence of pericardial effusion.  no evidence of intracardiac mass or thrombus.  doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  there is mild tricuspid regurgitation.  calculated pulmonary systolic pressure 42 mmhg. echocardiographic diagnoses:1.  lv ejection fraction, estimated at 65%.2.  mild left atrial enlargement.3.  mild tricuspid regurgitation.4.  mildly elevated pulmonary systolic pressure."
+"history of present illness:  the patient is a 36-year-old female with past medical history of migraine headaches, who was brought to the er after she was having uncontrolled headaches.  in the er, the patient had a ct scan done, which was reported negative, and lumbar puncture with normal pressure and the cell count, and was admitted for followup.  neurology consult was called to evaluate the patient in view of the current symptomatology.  the headaches were refractory to the treatment.  the patient has been on topamax and maxalt in the past, but did not work and according to the patient she got more confused. past medical history:  history of migraine. past surgical history:  significant for partial oophorectomy, appendectomy, and abdominoplasty. social history:  no history of any smoking, alcohol, or drug abuse.  the patient is a registered nurse by profession. medications:  currently taking no medication. allergies:  no known allergies. family history:  nothing significant. review of systems:  the patient was considered to ask systemic review including neurology, psychiatry, sleep, ent, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy, immunology, endocrinology, toxicology, oncology, and was found to be positive for the symptoms mentioned in the history of the presenting illness. physical examinationvital signs:  blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.heent:  head, normocephalic, atraumatic.  neck supple.  throat clear.  no discharge from the ears or nose.  no discoloration of conjunctivae and sclerae.  no bruits auscultated over temple, orbits, or the neck.lungs:  clear to auscultation.cardiovascular:  normal heart sounds.abdomen:  benign.extremities:  no edema, clubbing or cyanosis.skin:  no rash.  no neurocutaneous disorder.mental status:  the patient is awake, alert and oriented to place and person.  speech is fluent.  no language deficits.  mood normal.  affect is clear.  memory and insight is normal.  no abnormality with thought processing and thought content.  cranial nerve examination intact ii through xii.  motor examination:  normal bulk, tone and power.  deep tendon reflexes symmetrical.  downgoing toes.  no sign of any myelopathy.  cortical sensation intact.  peripheral sensation grossly intact.  vibratory sense not tested.  gait not tested.  coordination is normal with no dysmetria. impression:  intractable headaches, by description to be migraines.  complicated migraines by clinical criteria.  rule out sinusitis.  rule out vasculitis including temporal and arthritis, lupus, polyarthritis, moyamoya disease, takayasu and kawasaki disease. plan and recommendations:  the patient to be given a trial of the prednisone with a plan to taper off in 6 days, as she already had received 50 mg today.  depakote as a part of migraine prophylaxis and fioricet on p.r.n. basis. the patient to get vasculitis workup, as it has not been ordered by the primary care physician initially.  the patient already had mri of the brain and the cervical spine.  mri of the brain reported negative and cervical spine as shown signs of disk protrusion at c5 and c6 level, which will not explain of the temporal headache.  plan and followup discussed with the patient in detail."
+"ct abdomen without contrast and ct pelvis without contrast reason for exam:  evaluate for retroperitoneal hematoma, the patient has been following, is currently on coumadin. ct abdomen:  there is no evidence for a retroperitoneal hematoma. the liver, spleen, adrenal glands, and pancreas are unremarkable.  within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  a 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  no calcifications are noted.  the kidneys are small bilaterally. ct pelvis:  evaluation of the bladder is limited due to the presence of a foley catheter, the bladder is nondistended.  the large and small bowels are normal in course and caliber.  there is no obstruction. bibasilar pleural effusions are noted. impression:1. no evidence for retroperitoneal bleed.2. there are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.3. the kidneys are small in size bilaterally.4. bibasilar pleural effusions."
+"preoperative diagnosis:  colon polyps. postoperative diagnoses:1.  universal diverticulosis.2.  nonsurgical internal hemorrhoids. procedure performed: total colonoscopy with photos. anesthesia:  demerol 100 mg iv with versed 3 mg iv. specimens:  none. estimated blood loss:  minimal. indications for procedure:  the patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck. procedure:  informed consent was obtained.  all risks and benefits of the procedure were explained and all questions were answered.  the patient was brought back to the endoscopy suite where he was connected to cardiopulmonary monitoring.  demerol 100 mg iv and versed 3 mg iv was given in a titrated fashion until appropriate anesthesia was obtained.  upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  the colonoscope was then placed into the anus and the air was insufflated.  the scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  after reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis. upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  the scope was then subsequently removed.  the patient tolerated the procedure well and there were no complications."
+"history:  the patient is a 5-1/2-year-old with down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  as an infant, he was initially palliated with the right and modified blalock-taussig shunt in october of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  he developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the san diego at children&#8217;s hospital.  this was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm contegra valve.  a recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmhg and a well-functioning contegra valve.  the lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  the patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries. procedure:  after sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  the patient was prepped and draped.  cardiac catheterization was performed as outlined in the attached continuation sheets.  vascular entry was by percutaneous technique, and the patient was heparinized.  monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures using a 7-french sheath, 6-french wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  this catheter was exchanged over wire.  a 5-french marker pigtail catheter was directed into the main pulmonary artery.  a second site of venous access was achieved in and the left femoral vein with the placement of 5-french sheath. using a 4-french sheath, a 4-french pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  the distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  the distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  the left femoral venous sheath was exchanged over wire for a 7-french sheath.  guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two z-med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  the balloon catheter was then exchanged for a 5-french mistique catheter for pressure pull-back and measurement in the angiogram.  the catheter&#8217;s wires were then removed and final hemodynamic assessment was made with the wedge catheter. flows were calculated by the fick technique using a measured assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity. cineangiograms were obtained with angiograph injection in the main pulmonary artery. after angiography, two normal-appearing renal collecting systems were visualized.  the catheters and sheaths were removed and topical pressure applied for hemostasis.  the patient was returned to the recovery room in satisfactory condition.  there were no complications. discussion:  oxygen consumption was assumed to be in normal.  mixed venous saturation that was not normal with no evidence of intracardiac shunt.  left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmhg.  aphasic right atrial pressures were normal with an a-wave similar to the normal right ventricular end-diastolic pressure.  left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  there was a 20 mmhg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  right and left pulmonary artery capillary wedge pressures were normal with an a-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmhg.  left ventricular systolic pressure was systemic.  no outflow constriction to the ascending aorta.  phasic ascending and descending pressures were similar and normal.  the calculated systemic and pulmonary flows were equal and normal.  vascular resistances were normal.  angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning contegra valve with no appreciable calcification.  the proximal narrowing of the distal main pulmonary artery was appreciated.  neointimal ingrowth within the proximal stents were appreciated.  there is good distal growth of the pulmonary arteries.  arborization appeared normal.  levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  right ventricular systolic pressure felt slightly to 40 mmhg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  the main pulmonary pressures remained similar.  there was 10 mmhg systolic gradient into the branch of pulmonary arteries.  there is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmhg to 21 mmhg.  final angiogram with injection in the main pulmonary artery showed a competent contegra valve.  a brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  there was no evidence of intimal disruption. diagnoses: 1.  atrioventricular septal defect.2.  tetralogy of fallot with the pulmonary atresia.3.  bilateral superior vena cava.  the left cava draining to the coronary sinus.4.  the right aortic arch.5.  discontinuous pulmonary arteries.6.  down syndrome. prior surgeries and interventions:  1.  right modified blalock-taussig shunt.2.  repair of tetralogy of fallot with external conduit.3.  the atrioventricular septal defect repair.4.  unifocalization of branch pulmonary arteries.5.  bilateral balloon pulmonary angioplasty and stent implantation.6.  pulmonary valve replacement with 16-mm contegra valve. current diagnoses:  1.  mild-to-moderate proximal branch pulmonary stenosis.2.  well-functioning contegra valve and current intervention.  a balloon dilation of the right pulmonary artery.3.  balloon dilation of left pulmonary artery. management:  the case will be discussed at combined cardiology and cardiothoracic surgery case conference and conservative outpatient management will be pursued.  further cardiologic care be directed by dr. x."
+"procedure performed:1. left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.2. right femoral selective angiogram.3. closure device the seal the femoral arteriotomy using an angio-seal. indications for procedure: the patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. she has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. the decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression. description of procedure: after informed consent was obtained, the patient was taken to cardiac catheterization lab where her procedure was performed. she was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. then, a 6-french sheath was inserted into the right femoral artery over a standard 0.035 guide wire. coronary angiography and left ventricular measurement and angiography were performed using a 6-french jl4 diagnostic catheter to image the left coronary artery. a 6-french jr4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. subsequently, a 6-french angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 ml per second for a total of 30 ml. at the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. as such, an initial attempt to advance a perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. as such, the perclose was never deployed and was removed intact over the wire from the system. we then replaced this with a 6-french angio-seal which was used to seal the femoral arteriotomy with achievement of hemostasis. the patient was subsequently dispositioned back to the mac unit where she will complete her bedrest prior to her disposition to home. hemodynamic data: opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. there was no significant gradient across the aortic valve on pullback from the left ventricle. left ventricular ejection fraction was 55%. mitral regurgitation was less than or equal to 1+. there was normal wall motion in the rao projection. coronary angiogram: the left main coronary artery had mild atherosclerotic plaque. the proximal lad was 100% occluded. the left circumflex had mild diffuse atherosclerotic plaque. the obtuse marginal branch which operates as an om-2 had a mid approximately 80% stenosis at a kink in the artery. this appears to be the area of a prior anastomosis, the saphenous vein graft to the om. this is a very small-caliber vessel and is 1.5-mm in diameter at best. the right coronary artery is dominant. the native right coronary artery had mild proximal and mid atherosclerotic plaque. the distal right coronary artery has an approximate 40% stenosis. the posterior left ventricular branch has a proximal 50 to 60% stenosis. the proximal pda has a 40 to 50% stenosis. the saphenous vein graft to the right pda is widely patent. there was competitive flow noted between the native right coronary artery and the saphenous vein graft to the pda. the runoff from the pda is nice with the native proximal pda and plv disease as noted above. there is also some retrograde filling of the right coronary artery from the runoff of this graft. the saphenous vein graft to the left anterior descending is widely patent. the lad beyond the distal anastomosis is a relatively small-caliber vessel. there is some retrograde filling that allows some filling into a more proximal diagonal branch. the saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. overall, this study does not look markedly different than the procedure performed in 2004. conclusion: 100% proximal lad mild left circumflex disease with an om that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. the native right coronary artery has mild to moderate distal disease with moderate plv and pda disease. the saphenous vein graft to the om is known to be 100% occluded. the saphenous vein graft to the pda and the saphenous vein graft to the lad are open. normal left ventricular systolic function. plan: the plan will be for continued medical therapy and risk factor modification. aggressive antihyperlipidemic and antihypertensive control. the patient&#8217;s goal ldl will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking. after her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. we will also plan to perform a carotid duplex doppler ultrasound to evaluate her carotid bruits."
+"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."
+"preoperative diagnoses:  colon cancer screening and family history of polyps. postoperative diagnosis:  colonic polyps. procedure:  colonoscopy. anesthesia:  mac description of procedure:  the olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  the preparation was excellent and all surfaces were well seen.  the mucosa was normal throughout the colon and in the terminal ileum.  two polyps were identified and were removed.  the first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  the second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  no other lesions were identified.  numerous diverticula were found in the sigmoid colon.  a retroflex through the anorectal junction showed moderate internal hemorrhoids.  the patient tolerated the procedure well and was sent to the recovery room. final diagnoses:1.  sigmoid diverticulosis.2.  colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.3.  internal hemorrhoids.4.  otherwise normal colonoscopy to the terminal ileum. recommendations:1.  follow up biopsy report.2.  follow up with dr. x as needed.3.  screening colonoscopy in 5 years."
+"preprocedure diagnosis:  abdominal pain, diarrhea, and fever. postprocedure diagnosis:  pending pathology. procedures performed:  colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.     indications:  the patient is a 28-year-old female with history of abdominal pain, diarrhea, and fever.  colonoscopy is indicated to evaluate for etiology. description of procedure:  the patient was brought to the endoscopy suite with iv fluids being administered.  she was given a total of 300 mcg of fentanyl and 15 mg of versed, titrated for conscious iv sedation.  her heart rate, heart rhythm, blood pressure, respiratory rate, and oxygen saturation were monitored throughout the procedure.  she remained hemodynamically stable throughout the procedure.  the procedure began with a digital rectal examination.  the scope was then placed through the anus and advanced without difficulty to the terminal ileum.  there was what appeared to be some inflammation of the terminal ileum.  this was biopsied.  the scope was then withdrawn into the cecum, where biopsies were obtained.  the scope was then slowly withdrawn throughout the entire length of the colon.  the prep was adequate, but multiple syringes of irrigation were necessary to irrigate out some of the residual stool and allow for better visualization of the colonic mucosa.  there was an area of induration and inflammation at the hepatic flexure.  this was biopsied.  the scope was again withdrawn throughout the length of the colon.  there was also some area of inflammation in the sigmoid colon with narrowing.  again, these findings were seen on the way in with the colonoscope and were not due to scope trauma or the procedure itself.  further biopsies were obtained of the sigmoid colon in this area of narrowing.  total biopsies included terminal ileum, cecum, hepatic flexure, and sigmoid colon.  the scope was then withdrawn into the rectum.  retroflexion showed a normal-appearing anal canal with no internal hemorrhoids or fissures.  other than the areas of inflammation, there were no other abnormalities identified, no av malformations, no polyps, no diverticulum.  the patient tolerated the procedure well.  there were no immediate postprocedure complications."
+"reason for consultation:  renal failure. history of present illness:  thank you for referring ms. abc to abcd nephrology.  as you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to xyz hospital.  she had been admitted at that time with chest pain and was subsequently transferred to university of a and had a cardiac catheterization, which did not show any coronary artery disease.  she also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  her creatinine both at xyz hospital and university of a was elevated at 2.4.  i do not have the results from the prior years.  a repeat creatinine on 08/16/06 was 2.3.  the patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  she also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  she had bladder studies a long time ago.  she complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  she also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  she denies any nonsteroidal antiinflammatory drug use.  she denies any other over-the-counter medication use.  she has chronic hypokalemia and has been on potassium supplements recently.  she is unsure of the dose.   past medical history: 1.  hypertension on and off for years.  she states she has been treated intermittently but lately has again been off medications.2.  gastroesophageal reflux disease.3.  gastritis.4.  hiatal hernia.5.  h. pylori infection x3 in the last six months treated.6.  chronic hypokalemia secondary to chronic diarrhea.7.  recurrent admissions with nausea, vomiting, and dehydration.  8.  renal cysts found on a cat scan of the abdomen.9.  no coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  10.  stomach bypass surgery 1975 with chronic diarrhea.11.  history of uti multiple times recently.12.  questionable history of kidney stones.13.  history of gingival infection secondary to chronic steroid use, which was discontinued in july 2001.14.  depression.15.  diffuse degenerative disc disease of the spine.16.  hypothyroidism.17.  history of iron deficiency anemia in the past.  18.  hyperuricemia.  19.  history of small bowel resection with ulcerative fibroid.  20.  occult severe gi bleed in july 2001. past surgical history:   the patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck april 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor august 4, 2005.   current medications: 1.  nexium 40 mg q.d.2.  synthroid 1 mg q.d. 3.  potassium one q.d., unsure about the dose.  4.  no history of nonsteroidal drug use. allergies:   sulfa causes hives.   transfusions:   transfusion in 1993. family history:  mother is deceased at the age of 55 of breast cancer and also had type 2 diabetes.  father is deceased of known cause.  strong family history of diabetes in the mother, grandmother, sisters, maternal aunts, and uncles.  social history:   she works as a cook for a nursing home, is single and has one daughter.  never smoked.  denies any alcohol.  has not been sexually active in a long time.   review of systems:  positive for 5-6 pound weight loss in recent months.  poor appetite.  she wears glasses.  she complains of a funny sensation in the throat and clearing her throat all of the time.  gi:  she has recurrent nausea.  currently, has no active vomiting.  chronic diarrhea since the time of the bypass with eight watery stools per day.  she has joint aches and has all of the time spasms in both legs.  has had cysts removed in both breasts and recent mammogram in march 2006 was normal.  history of depression and high stress with multiple psychosomatic complaints in the past.  she reports that her fingersticks were high in the hospital and subsequently were rechecked and were normal.  history of iron deficiency anemia in the past.  allergies:  sulfa causes hives.   physical examination:  an overweight cushingoid-looking lady in no acute distress.  weight:  170 pounds.  temperature:  96.7.  blood pressure:  130/84.  respirations:  12.  pulse:  62.  heent:  conjunctivae are anicteric.  lids have no ptosis.  pupils are equal, round, and reacting to light.  optic disks are flat.  no hemorrhages.  ent:  appear normal.  mucosa is moist.  neck:  supple.  no jvd.  no thyromegaly.  lungs:  clear to auscultation.  cardiovascular:  normal heart sounds and 1/6 ejection systolic murmur.  pulses:  all peripheral pulses are present.  extremities:  no peripheral edema.  breasts:  inspection of the breasts is normal.  abdomen:  soft and nontender.  normal bowel sounds.  multiple surgical scars.  multiple striae.  no bruit.  no hepatosplenomegaly.  lymphatic:  no neck, axillary, or groin lymphadenopathy.  musculoskeletal:  gait and station are normal.  no clubbing or cyanosis.  skin:  no rashes.  neurological:  cranial nerves are intact.  deep tendon reflexes are 2+.  strength is 5/5.  psychiatric:  judgment and insight are good.  orientation to time, place, and person is normal.   laboratory data:  laboratory data on 08/16/06:  bun 15, creatinine 2.3, sodium 142, potassium 3.4, chloride 102, uric acid 9.2, and albumin 3.9.   in august 2006, bun 25 and creatinine 2.4. on august 11, 2006:  hematocrit 37.3, hemoglobin 12.5, platelets 96,000, and white count 7.6. ua done today:  specific gravity 1.015, blood trace, ph 5.5, and leukocyte esterase moderate. on microscopy:  there were few rbcs, some crystals, and multiple wbcs. a ct of the chest report brought by the patient from 03/07/06:  stable splenomegaly, no evidence of liver metastasis, nonspecific dilated small bowel loops with a questionable possible idiopathic changes, and tiny benign cysts in the posterior aspect of the right kidney.  the left kidney demonstrated a 1-cm cyst in the posterior aspect of the left kidney. a dexa scan report from 05/04/01 was normal.   assessment and plan:1.  renal.  this patient has chronic kidney disease stage 4 with an estimated creatinine clearance of 23 ml/minute.  i unsure whether this renal failure is recent or she has had slow progression of her renal failure.  i would appreciate it if you could forward the results of any laboratory tests done in the last two to three years to determine her creatinine.  i am unsure of the exact etiology of her renal failure.  i ordered a renal ultrasound to evaluate the kidney size and also to evaluate if she has been emptying her bladder completely.  the patient does report that she has dribbling of urine and some incontinence.  also, i ordered a comprehensive metabolic panel, cbc, intact pth, hepatitis b and c panel, and a 24-hour urine for protein and creatinine clearance.  the patient has had recurrent utis in the past and it is possible that she has had chronic pyelonephritis and scarring resulting in chronic renal failure.  she has a urinary tract infection currently with multiple wbcs on the microscopy.  i prescribed ciprofloxacin 250 mg q.d. for 10 days and we will send her urine out for cultures, and we adjust her antibiotics if her urine cultures shows resistant organisms.  i explained to the patient that if her renal function continues to worsen we might need to discuss renal replacement therapy with regards to either transplantation or dialysis.  we will address this issue after the results are available.  i also ordered a postvoid residual to see if she is emptying her bladder completely.  i have advised her not to use any nonsteroidal antiinflammatory drugs.  2.    hypertension.  blood pressure is controlled off medications.  we will reevaluate the blood pressure            on the next visit.  3.    urinary tract infection.  prescribed cipro 250 mg q.d. pending cultures.4.    chronic diarrhea.  the patient states she has tried multiple agents with no relief of the diarrhea.  5.    chronic hypokalemia.  the patient has been advised to call in with the potassium dose.  6.    follow up in six weeks."
+observations:  the forced vital capacity is 2.84 l and forced expiratory volume in 1 second is 1.93 l. the ratio between the two is 68%.  small improvement is noted in the airflows after bronchodilator therapy.  lung volumes are increased with a residual volume of 196% of predicted and total lung capacity of 142% of predicted.  single-breath diffusing capacity is slightly reduced. impression:  mild-to-moderate obstructive ventilatory impairment.  some improvement in the airflows after bronchodilator therapy.
+"reason for consultation:  abnormal echocardiogram findings and followup.  shortness of breath, congestive heart failure, and valvular insufficiency. history of present illness:  the patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools.  the patient has colitis and also diverticulitis, undergoing treatment.  during the hospitalization, the patient complains of shortness of breath, which is worsening.  the patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.  this consultation is for further evaluation in this regard.  as per the patient, she is an 86-year-old female, has limited activity level.  she has been having shortness of breath for many years.  she also was told that she has a heart murmur, which was not followed through on a regular basis. coronary risk factors:  history of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory. family history:  nonsignificant. past surgical history:  no major surgery. medications:  presently on lasix, potassium supplementation, levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation. allergies:  ambien, cardizem, and ibuprofen. personal history:  she is a nonsmoker.  does not consume alcohol.  no history of recreational drug use. past medical history:  basically gi pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur. review of systemsconstitutional:  weakness, fatigue, and tiredness.heent:  history of cataract, blurred vision, and hearing impairment.cardiovascular:  shortness of breath and heart murmur.  no coronary artery disease.respiratory:  shortness of breath.  no pneumonia or valley fever.gastrointestinal:  no nausea, vomiting, hematemesis, or melena.urological:  no frequency or urgency.musculoskeletal:  arthritis and severe muscle weakness.skin:  nonsignificant.neurological:  no tia or cva.  no seizure disorder.endocrine/hematological:  as above. physical examinationvital signs:  pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.heent/neck:  head is atraumatic and normocephalic.  neck veins flat.  no significant carotid bruits appreciated.lungs:  air entry bilaterally fair.  no obvious rales or wheezes.heart:  pmi displaced.  s1, s2 with systolic murmur at the precordium, grade 2/6.abdomen:  soft and nontender.extremities:  chronic skin changes.  feeble pulses distally.  no clubbing or cyanosis. diagnostic data:  ekg:  normal sinus rhythm.  no acute st-t changes. echocardiogram report was reviewed. laboratory data:  h&#038;h 13 and 39.  bun and creatinine within normal limits.  potassium within normal limits.  bnp 9290. impression:1.  the patient admitted for gastrointestinal pathology, under working treatment.2.  history of prior heart murmur with echocardiogram findings as above.  basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation. recommendations:1.  from cardiac standpoint, conservative treatment.  possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.2.  after extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.3.  based on the above findings, we will treat her medically with ace inhibitors and diuretics and see how she fares.  she has a normal lv function."
+"clinical indication:  normal stress test. procedures performed:1.  left heart cath.2.  selective coronary angiography.3.  lv gram.4.  right femoral arteriogram.5.  mynx closure device. procedure in detail:  the patient was explained about all the risks, benefits, and alternatives of this procedure.  the patient agreed to proceed and informed consent was signed. both groins were prepped and draped in the usual sterile fashion.  after local anesthesia with 2% lidocaine, a 6-french sheath was inserted in the right femoral artery.  left and right coronary angiography was performed using 6-french jl4 and 6-french 3drc catheters.  then, lv gram was performed using 6-french pigtail catheter.  post lv gram, lv-to-aortic gradient was obtained.  then, the right femoral arteriogram was performed.  then, the mynx closure device was used for hemostasis.  there were no complications. hemodynamics:  lvedp was 9.  there was no lv-to-aortic gradient. coronary angiography:1.  left main is normal.  it bifurcates into lad and left circumflex.2.  proximal lad at the origin of big diagonal, there is 50% to 60% calcified lesion present.  rest of the lad free of disease.3.  left circumflex is a large vessel and with minor plaque.4.  right coronary is dominant and also has proximal 40% stenosis. summary:1.  nonobstructive coronary artery disease, lad proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.2.  rca has 40% proximal stenosis.3.  normal lv systolic function with lv ejection fraction of 60%. plan:  we will treat with medical therapy.  if the patient becomes symptomatic, we will repeat stress test.  if there is ischemic event, the patient will need surgery for the lad lesion.  for the time being, we will continue with the medical therapy."
+"indications:  preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture. history of present illness:  the patient is a 78-year-old white female with no prior cardiac history.  she sustained a mechanical fall with a subsequent left femoral neck fracture.  she was transferred to xyz hospital for definitive care.  in the emergency department of xyz, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  electrocardiogram was obtained, which showed nonspecific st-segment flattening in the high lateral leads i, avl.  she also had a left axis deviation.  serial troponins were obtained.  she has had four negative troponins since admission.  due to age and chest pain history, a cardiology consultation was requested preoperatively. at the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia. past medical history:1.  mesothelioma.2.  recurrent urinary tract infections.3.  gastroesophageal reflux disease/gastritis.4.  osteopenia.5.  right sciatica.6.  hypothyroidism.7.  peripheral neuropathy.8.  fibromyalgia.9.  chart review also suggests she has atherosclerotic heart disease and pneumothorax.  the patient denies either of these. past surgical history:1.  tonsillectomy.2.  hysterectomy.3.  appendectomy.4.  thyroidectomy.5.  coccygectomy.6.  cystoscopies times several.7.  bladder neck resuspension.8.  multiple breast biopsies. allergies:  no known drug allergies. medications:  at the time of evaluation include, 1.  cefazolin 1 g intravenous (iv).  2.  morphine sulfate.  3.  ondansetron p.r.n. outpatient medications:  1.  robaxin.  2.  detrol 4 mg q.h.s.  3.  neurontin 300 mg p.o. t.i.d.  4.  armour thyroid 90 mg p.o. daily.  5.  temazepam, dose unknown p.r.n.  6.  chloral hydrate, dose unknown p.r.n. family history:  mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  she knows nothing of her father&#8217;s history.  she has no siblings.  there is no other history of premature atherosclerotic heart disease in the family. social history:  the patient is married, lives with her husband.  she is a lifetime nonsmoker, nondrinker.  she has not been getting regular exercise for approximately two years due to chronic sciatic pain. review of systems: general:  the patient is able to walk one block or less prior to the onset of significant leg pain.  she ever denies any cardiac symptoms with this degree of exertion.  she denies any dyspnea on exertion or chest pain with activities of daily living.  she does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  she does have chronic lower extremity edema.  her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  she denies any palpitations or tachycardia.  she has remote history of presyncope, no true syncope.hematologic:  negative for bleeding diathesis or coagulopathy.oncologic:  remarkable for past medical history.pulmonary:  remarkable for childhood pneumonia times several.  no recurrent pneumonias, bronchitis, reactive airway disease as an adult.gastrointestinal:  remarkable for past medical history.genitourinary:  remarkable for past medical history.musculoskeletal:  remarkable for past medical history.central nervous system:  negative for tic, tremor, transient ischemic attack (tia), seizure, or stroke.psychiatric:  remarkable for history of depression as an adolescent, she was hospitalized at state mental institution as a young woman.  no recurrence. physical examination:general:  this is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.vital signs:  she has had a low-grade temperature of 100.4 degrees fahrenheit on 11/20/2006, currently 99.6.  pulse ranges from 123 to 86 beats per minute.  blood pressure ranges from 124/65 to 152/67 mmhg.  oxygen saturation on 2 l nasal cannula was 94%.heent:  exam is benign.  normocephalic and atraumatic.  extraocular motions are intact.  sclerae anicteric.  conjunctivae noninjected.  she does have bilateral arcus senilis.  oral mucosa is pink and moist.neck:  jugular venous pulsations are normal.  carotid upstrokes are palpable bilaterally.  there is no audible bruit.  there is no lymphadenopathy or thyromegaly at the base of the neck.  there is a well-healed scar at the base of the neck.  cardiothoracic contour is normal.lungs:  limited to anterior auscultation only, which was clear.cardiac:  regular rhythm and rate.  s1 and s2 with no significant murmur, rub, or gallop appreciated.  the point of maximal impulse is normal.  there is no right ventricular heave.abdomen:  soft with active bowel sounds.  no organomegaly.  no audible bruit.  nontender.extremities:  femoral pulses were deferred.  lower extremities revealed trace to 1+edema at the level of ankles bilaterally. diagnostic data:  ekg:  electrocardiogram on 11/20/2006 at 1539 showed sinus rhythm with left axis deviation, borderline first-degree atrioventricular (av) block, sinus arrhythmia.  nonspecific st-segment flattening seen predominantly in avl, but to a lesser extent in lead i. early r-wave progression also noted.  no evidence for resting ischemia or prior infarction.  repeat electrocardiogram on 11/21/2006 at 0037 essentially unchanged with regard to st segments except there is perhaps slightly more flattening in lead i. p-wave morphology is slightly different than that noted on prior tracing consistent with ectopic atrial rhythm.  repeat electrocardiogram on 11/21/2006 at 1713 shows persistence of st segment flattening in lead i, avl.  persistence of early r-wave progression and left axis deviation.  rhythm does appear to be sinus on current tracing. laboratory data:  white blood cell count 4.7 on admission, hematocrit currently 33.2 with platelet count of 243 on admission.  inr 1.0 with ptt of 20.  sodium 144 with potassium 3.6, chloride 107, co2 25, bun 10 with creatinine of 1.1.  albumin depressed at 3.3.  ast and alt normal at 19 and 24 respectively, lipase normal at 45.  troponins are negative x4 over the course of 14 hours.  urinalysis is suggestive of urinary tract infection (uti) with no blood, positive nitrates, positive leuk esterase, 5 to 10 white blood cells, and many bacteria with no epithelial cells. impression:  elderly white female status post traumatic left hip fracture with atypical chest pain and baseline st-segment abnormalities nondiagnostic. recommendations:1.  cardiac clearance:  the patient with cardiac risk factors including age and family.  not smoking, hypertensive, dyslipidemic.  does have a sedentary lifestyle, but it is not morbidly obese.  given the atypical nature of her chest pain and the nondiagnostic ekg changes, i feel it is safe to proceed with orthopedic procedure without further cardiac evaluation.  we would, however, treat with preoperative beta-blockers.2.  we will follow the patient perioperatively with electrocardiogram and troponin.3.  we would recommend treatment for presumed urinary tract infection. followup:  the patient will be followed in-house by members of cardiology associates and recommendations made as clinically appropriate."
+"cc: transient visual field loss. hx: this 58 y/o rhf had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. she was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. hct and mri brain revealed bilateral posterior clinoid masses. meds: colace, quinidine, synthroid, lasix, lanoxin, kcl, elavil, tenormin. pmh: 1) obesity.  2) vbg, 1990.  3) a-fib. 4) htn.  5) hypothyroidism.  6) hypercholesterolemia. 7) briquet&#8217;s syndrome: h/o of hysterical paralysis. 8) cll, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with cll and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cgy to right parotid mass. 9) snhl fhx: father died, mi age 61. shx: denied tobacco/etoh/illicit drug use. exam: vitals were unremarkable. the neurologic exam was unremarkable except for obesity and mild decreased pp about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. the neuro-ophthalmologic exam was unremarkable, per neuro-ophthalmology. course: she underwent cerebral angiography on 1/8/91. this revealed a 15x17x20mm lica paraclinoid/ophthalmic artery aneurysm and a 5x7mm rica paraclinoid/ophthalmic artery aneurysm. on 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. the aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. she has complained of headaches since."
+"preliminary diagnoses:1.  contusion of the frontal lobe of the brain.2.  closed head injury and history of fall.3.  headache, probably secondary to contusion. final diagnoses:1.  contusion of the orbital surface of the frontal lobes bilaterally.2.  closed head injury.3.  history of fall. course in the hospital:  this is a 29-year-old male, who fell at home.  he was seen in the emergency room due to headache.  ct of the brain revealed contusion of the frontal lobe near the falx.  the patient did not have any focal signs.  he was admitted to abcd.  neurology consultation was obtained.  neuro checks were done.  the patient continued to remain stable, although he had some frontal headache.  he underwent an mri to rule out extension of the contusion or the possibility of a bleed and the mri of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  the patient remained clinically stable and his headache resolved.  he was discharged home on 11/6/2008. plan:  discharge the patient to home. activity:  as tolerated. the patient has been advised to call if the headache is recurrent and tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  the patient has been advised to follow up with me as well as the neurologist in about 1 week."
+"comprehensive clinical psychological evaluation current medications:  nexium 4 mg 4 times per day, propanolol 10 mg 4 times a day, spironolactone 100 mg 3 times per day, lactulose 60 cc&#8217;s 3 times a day. general observations:  mr. abc, a 54-year-old black married male who was referred for a comprehensive clinical psychological evaluation as part of a disability determination action.  mr. abc arrived five minutes late for his scheduled appointment.  he was accompanied to the office by his sister-in-law who drove him to the appt.  mr. abc currently does not receive disability benefits.  this is the first time he has filed for disability.  the authorization form listed mr. abc&#8217;s current complaints as &quot;cirrhosis of the liver and mental issues.&quot;  mr. abc was well groomed and wore casual attire.  he looked older than his stated age.  the whites of his eyes were very jaundiced.  his posture was slightly stooped and his gait was slow.  he was winded after walking up the stairs.  psychomotor activity was retarded.  mr. abc was cooperative throughout the interview.  although he appeared to be answering most questions to the best of his ability, he appeared to be minimizing his emotional distress.   present illness:  most information was provided by mr. abc who appeared to be a fairly reliable source.  his information was supplemented by review of his medical records.  mr. abc has applied for federal disability benefits believing that he qualifies based on his cirrhosis of the liver and his cognitive dysfunction.  mr. abc was diagnosed with cirrhosis in 1991.  his condition has worsened to the point that he is experiencing liver failure and is awaiting a liver transplant.  he stated that his main symptom is extreme fatigue.  he has no energy and is unable to engage in many activities.  over the past year he was admitted to the hospital four times for confusion and bizarre behavior.  he stated that his sister-in-law and his wife told him that he had become violent and he fought with the sherriff who was trying to take him to the hospital.  he has no memory of this.  mr. abc stated that he was hospitalized one time.  actually he had begun having problems with confusion in july of 2004 and he has been treated four times since that time.  according to his medical records, he was found wandering outside of his home.  he was apparently delusional believing that a tree branch was a doorknob.  mr. abc also suffers from edema and swelling in his legs and his feet.  mr. abc attempted to return to work and found that he was unable to do his job due to the necessity of walking one-quarter mile from the front to the back of the plant.  he was unable to walk very far without becoming fatigued.  he had instances where he had passed out after becoming faint.  he had trouble at work sitting for very long because his feet swelled.  he was unable to lift the required 10 pounds of medication boxes.  when he found himself unable to do his regular job, he tried another job at the same plant but was unable to do that job.  he also became confused easily at work.  his doctor advised him to quit and then he did so in march of this year.  in addition to his cognitive symptoms, mr. abc has had some disturbance in mood as well.  he related that he feels very sad since he lost his job.  a lot of his self-esteem came from working.  he worries about financial problems.  his sleep has been disturbed.  he sleeps four to five hours a night with trouble falling asleep and frequent awakening in the middle of the night.  his appetite is fair.   personal, family and social history:  mr. abc completed the 11th grade. he went on to get his ged in 1971.  he stated that he has never failed a grade and he has no history of a learning disability.  he received no special education services.  his grades were bs and cs. he stated that he was suspended from school one time for fighting but got along well in general. mr. abc is currently unemployed.  his last job was at baxter health care where he worked for four years.  it was his longest place of employment.  he quit in march of 2005 because of fatigue and inability to perform the necessary job duties.  he denies that he was ever fired from a job and he reported good work relationships.  mr. abc has been married for two years. he has no prior marriages.  he has one daughter age 13.  he currently lives with his wife. has been at his current address for four years.   history of other pertinent medical events:  mr. abc has cirrhosis of the liver, hepatitis c, hepatic encephalopathy, and gastroesophageal reflux disease, and hypertension. surgeries include a cardiac catheterization in 2001, a liver biopsy in 2003.  over the past year he has been hospitalized four times due to confusion and bizarre behaviors stemming from his liver failure.   daily activities and functioning:  mr. abc stated that he tries to do things but he has been severely restricted due to his extreme fatigue.  he enjoys reading and does it regularly.  he tries to help his wife with the household chores as he can.  he has washed dishes, cooked, mopped, dusted, vacuumed and has done laundry occasionally over the past month but not as much as he used to.  he stated that he used to mow the yard and do yard work but he can no longer do it because of his extreme fatigue.  he has given up driving all together and he no longer goes out alone.  he spends most days at home.  he enjoys going to church and he prays daily.   mental health history:  mr. abc has never been diagnosed or treated for a mental health disorder.  he denied any history of mental health problems in his family.  he stated that he was evaluated one time earlier this year by a psychiatrist to determine his suitability for a liver transplant.  he was approved and he is now on the waiting list to receive a liver.   substance use history:  mr. abc has a history of substance use beginning in his teenage years.  he has used alcohol, marijuana and cocaine.  he stated that he only used the marijuana and cocaine a few times when he was young but he continued using alcohol until recently.  his alcohol use became problematic and he was arrested for dwi three times.  he attended aa and the dart program.  mr. abc stated that he has been clean for eight years and five months.     mental status:  mr. abc was given a four page questionnaire to complete.  he had only been able to complete a few answers after 20 minutes and then was observed letting his sister-in-law fill it out for him.  mr. abc was of average height and weight.  he was casually dressed and groomed appropriately.  he was missing a bottom front tooth.  he appeared his stated age.  he was alert and responsive.  he was oriented to time, person, place and situation.  he was cooperative throughout the interview.  eye contact was good.  psychomotor activity was retarded.  affect was constricted.  mood was sad.  speech was fluent and goal-directed.  mr. abc had a slight slur to his speech which may have been caused by his missing front tooth.  rates, rhythm and volume were within normal limits although he spoke on the slow side.  thought processes were coherent but mr. abc supplied a paucity of ideas. he seemed to have problems generating details of past events.  his answers were minimal and he used few words.  thought content focused on feeling bad about his limitations, his illness and losing his job.  he denied any delusional thoughts but apparently he has had some periods of delusional thinking in the past which has been documented in his medical record.  his memory was adequate for recent events.  his memory was impaired for remote events.  attention and concentration were adequate.  thinking was very concrete.  mr. abc denied any suicidal or homicidal thoughts or plans.  judgment and insight were adequate.  he reported that his sleep is impaired.  he sleeps four to five hours per night.  appetite is fair.  he denied any perceptual disturbances, but stated that he had had some illusions and visual hallucinations several years ago while he was having delirium tremens.   cognitive responses:  1.  who is the current president of the united states?  &quot;george bush.&quot;2.  name four large cities in the united states?  &quot;new york, la, houston, dallas.&quot;3.  why do we wash clothes?  &quot;so you&#8217;ll have something clean to wear.  i wouldn&#8217;t want to have to wear the same clothes the next day.&quot;4.  what should you do if while in the movies you are the first person to see smoke and fire?  &quot;i would go tell someone or if they have an alarm, i&#8217;d pull it.&quot;5.  what does the saying strike while the iron is hot mean?  &quot;if you&#8217;ve got a good thing going you better keep going.&quot;6.  how much is 12 plus 14?  &quot;26.&quot;  7.  how much is 18 minus six?  &quot;12.&quot;  8.  starting with 3 count by 3&#8242;s.  &quot;3, 6, 9, 12, 15, 18, 21.&quot;  (immediate response)9.  counting backwards from 30 by 2&#8242;s.  &quot;30, 28, 26, 24, 22, 20.&quot;  10.  what did you have for dinner last night?  &quot;salad, a little bit of spaghetti, ice water.&quot; (delayed response)11.  what did you watch on tv last night?  &quot;platoons, the news.&quot; 12.  what is today&#8217;s date?  &quot;july 21st, 2005.&quot;13.  in what town are you currently located?  &quot;morganton.&quot;14.  why are you here today?  &quot;to be evaluated.&quot;15.  immediate recall of ball, car, and hat.  &quot;car, ball, and hat.&quot; diagnostic impression:axis i:  mood disorder, nos.  cognitive disorder, nos.axis ii:  none.axis iii:  cirrhosis of the liver, hepatitis c, hepatic encephalopathy, gastroesophageal reflux disease. summary and conclusions:  mr. abc is estimated to be within the average range of intellectual functioning.  he has adequate insight and judgment.  he has filed for federal disability benefits, believing that he qualifies for them based on symptoms associated with his cirrhosis of the liver.  he has been experiencing extreme fatigue and has had to limit his activities because of it.  he has swelling in his extremities and is unable to sit for long periods of time.  he is unable to walk for even short distances without tiring.  he has been hospitalized four times over the past year due to cognitive problem, disorientation and bizarre behaviors.  at this time, mr. abc is experiencing some mood disturbance.  it appears that this might be secondary to his health problems but given the claimant&#8217;s tendencies to minimize his mental health symptoms and to fail to give adequate historical details, it is difficult to know for sure.  based on presentation, intellectually and cognitively, it is believed that mr. abc could not complete work-related tasks satisfactorily.  emotionally and socially, it is believed that he could not tolerate work stressors and could not adjust to a work environment and schedule.  at this time, it is believed that his cognitive dysfunction would be a hindrance to him in a work setting.   capability:  if mr. abc were to receive benefits, it appears that he would not need a payee."
+"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&#8217;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&#8217;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."
+"exam:  left heart catheterization reason for exam:  chest pain, coronary artery disease, prior bypass surgery. interpretation:  the procedure and complications were explained to the patient in detail and formal consent was obtained.  the patient was brought to the cath lab.  the right groin was draped in the usual sterile manner.  using modified seldinger technique, a 6-french arterial sheath was introduced in the right common femoral artery.  a jl4 catheter was used to cannulate the left coronary arteries.  a jr4 catheter was used to cannulate the right coronary artery and also bypass grafts.  the same catheter was used to cannulate the vein graft and also lima.  i tried to attempt to cannulate other graft with williams posterior catheter and also bypass catheter was unsuccessful.  a 6-french pigtail catheter was used to perform left ventriculography and pullback was done.  no gradient was noted.  arterial sheath was removed.  hemostasis was obtained with manual compression.  the patient tolerated the procedure very well without any complications. findings:1.  native coronary arteries.  the left main is patent.  the left anterior descending artery is not clearly visualized.  the circumflex artery appears to be patent.  the proximal segment gives rise to small caliber obtuse marginal vessel.2.  right coronary artery is patent with mild distal and mid segment.  no evidence of focal stenosis or dominant system.3.  bypass graft lima to the left anterior descending artery patent throughout the body as well the anastomotic site.  there appears to be possible _______ graft to the diagonal 1 vessel.  the distal lad wraps around the apex.  no stenosis following the anastomotic site noted.4.  vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.5.  no other bypass grafts are noted by left ventriculography and also aortic root shot.6.  left ventriculography with an ejection fraction of 60%. impression:1.  left coronary artery disease native.2.  patent vein graft with obtuse marginal vessel and also lima to lad.  _______ graft to the diagonal 1 vessel.3.  native right coronary artery is patent, mild disease. recommendations:  medical treatment."
+"identification of patient:  this is a 31-year-old female who was referred by herself.  she was formerly seen at counseling center.  she is a reliable historian. chief complaint:  &quot;i&#8217;m bipolar and i have severe anxiety disorder.  i have posttraumatic stress syndrome.&quot;  history of present illness:  at age 19, ms. abc had a recurrence of memories.  her father had molested her, and the memories returned.  in 1992, at the age of 18, she entered her first abusive marriage.  she was beaten and her husband shared her sexually with his friends.  this lasted until age 24.  the second marriage was age 26, her second husband was a drug abuser and &quot;he slapped me around.&quot;  she had two children during that marriage.  in 2001, she was married in indiana to a military man.  this was her third marriage and she stated, &quot;this marriage is good.&quot;  she had emdr in indiana when she was being treated for posttraumatic stress disorder.   historically, her first husband threw her down the stairs at age 21, and she had a miscarriage.  her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have.  currently, she is unable to have sex with the lights on.  she states, &quot;sometimes i hurt all over.&quot;  her husband was deployed three days ago, on april 21, to a foreign theater of operations.  she has panic attacks every day. review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells old spice aftershave.  she does not avoid thoughts of her trauma, but she avoids the perpetrators and placements.  she is not unable to recall details of her trauma.  she does feel detached and isolated.  she has restrictive range of affect and she had a foreshortened future.  she also had a loss of interest in things, starting at age 5.  she has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, &quot;i don&#8217;t do as good as i can.&quot;  further review of symptoms shows her to have periods of constant cleaning and increased sex drive.  she also has had euphoria, poor judgment, distractibility, and inability to concentrate.  she has been irritable.  she has had a decreased need for sleep, which lasts for six or seven days.  she had racing thoughts, rapid speech, but has not had grandiosity.  these symptoms of mania occurred in the last week of november 2005 and lasted for seven days from, which she was not hospitalized.  furthermore, she endorses the following symptoms:  she states, &quot;when i&#8217;m depressed, i have neck pain, jaw pain, abdominal pain.  i have migraines and urinary tract pain.&quot;  she also complains of chest pain, pain during sex, and excess pain during her menstrual period.  she has an increased gag reflex, which has caused her to have emesis.  she states it is easy to choke.  she has had physical symptoms, &quot;for as long as i can remember,&quot; and she states, &quot;i&#8217;ve felt like crap most of my life,&quot;  &quot;it affects my marriage.&quot;  she has also admitted to having nausea and vomiting, with excess gas.  she has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea.  she states that sex is only important to her in mania.  otherwise, she has no desire.  she has had irregular periods for two or three weeks at a time.  she has had no episodes of excess bleeding.  she has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion.  currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of lunesta.  her energy is &quot;not good.  her appetite is &quot;i&#8217;m craving crap,&quot; stating that she wants to eat carbohydrates.  concentration is poor today.  she feels worthless, hopeless, and guilty.  her self-esteem is &quot;i don&#8217;t have any.&quot;  she has no anhedonia, and she has no libido.  she also has had feelings of chronic emptiness.  she feels abandoned.  she has had unstable relationships.  she self-mutilated, but she stopped at age 22.  she has trouble controlling her anger.  she did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child.  she has no identity disturbance.   current medications:  seroquel 700 mg p.o. q.d.; wellbutrin xl 300 mg p.o. q.d.; desyrel 100 mg p.o. q.h.s.; ativan p.r.n. dosage unknown.  in the past, she has been on prozac, paxil, lithium, depakote, depakene, and zoloft.  psychiatric history:  she saw dr. b.  she saw chris.  she is diagnosed with posttraumatic stress disorder, depression, and bipolar disorder.  she had counseling in indiana in 2001.  she had inpatient treatment in indiana in 2001 also, at age 19.  she had three suicide attempts.  at age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more.  she has had no psychological testing.   medical history:  significant for migraines, hyperactive and gag reflex.  she states she has had cardiovascular workups due to panic disorder, but nothing was found.  she also has astigmatism.  she states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy.  she has no history of head injury or mri test of the brain.  no history of eeg, seizures, thyroid problems, or asthma.  there are no drug allergies.  she has never had an ekg.  she does have musculoskeletal problems and has arthritis-like joint pains on occasion.  she has had ear infections and sinus infections intermittently.  hearing test was normal.  she is currently not pregnant.  she saw her gynecologist four months ago at elmendorf air force base.   surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19.  she had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown.   she has no hypertension, no diabetes, no glaucoma. family history:  significant for her paternal grandmother not being mentally competent.  her mother was depressed and was treated.  her mother is currently age 55.  she has a paternal grandmother who may have had schizophrenia.  there is also a family history of the paternal grandfather using substance.  he was &quot;an extreme alcoholic.&quot;  she had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess.  the maternal uncle committed suicide; he drowned himself.   there is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, tourette&#8217;s syndrome, or learning disabilities.  medical history in the family is significant for her son, age 4, who is having seizures ruled out.  her mother and two maternal aunts have thyroid disease.  she has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer.  there is no family history of hypertension. abuse history:  significant for being physically abused by her father, her first husband, and her second husband.  she was sexually abused by her father from age 5 to age 18.  she states, &quot;my first husband gave me away for four years to his friends to be used sexually.&quot;  she was emotionally abused by her mother, father, and both of her first two husbands.  she was neglected by her mother and her father.  she never witnessed domestic violence.  she has not witnessed traumatic events.   substance abuse:  significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early.  she has never used alcohol, tobacco, marijuana, or any other drugs. parent/sibling relationship information:  she had had a poor relationship with her parents.  she has no contact with them.  she has no contact with her brother.  she was married three times, as stated in the history.  she has two children with asperger&#8217;s and autism.   hobbies/spiritual:  she likes to read and write.  she likes to cross-stitch, quilt, and do music, and has found a good church in anchorage.   educational:  she states she was teased in school because &quot;i was so depressed.&quot;  she got good grades otherwise.  she finished high school. work history:  she has worked in the past managing a dollar general store.  she has been a waitress and an executive secretary.   legal history:  she has never been arrested. mental status:  significant for a well groomed, well kempt young white female who appears her stated age.  she has a pierced nose and has a nose ring.  she is cooperative, alert, and attentive.  she makes good eye contact.  her speech is normal, prosody is normal, and rate and rhythm are normal.  motor is normal.  she has no gait abnormalities.  no psychomotor retardation or agitation.  her mood is &quot;i&#8217;m sad and depressed.&quot;  her affect is restricted.  she is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews.  perception is normal.  she denies auditory and visual hallucinations.  she denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred.  otherwise, she has not had dissociative phenomena.  thought processes are normal.  she has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality.  she is goal directed and oriented.  insight and judgment are good.  she is alert and oriented to person, place, and time, stating it was 04/18/06, tuesday, it was anchorage in the spring.  she is able to register three words and recall them at five minutes.  she is able to do simple calculations, stating 2&#215;3 is 6, and 1 dollar 15 cents has 23 nickels.  she is given a proverb to interpret.  she was asked what judging a book by its cover meant.  she said, &quot;you can&#8217;t always tell what a person is by looking at them on the outside.&quot;  she is appropriate in her abstraction, and is able to identify the last four presidents. clinical impression:  abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis.  she has had an extensive history of sexual abuse and emotional abuse.  she has not used drugs and alcohol, and she has been treated in the past.  she was treated with emdr and stated that she did not benefit from that.  she has an extensive medical history and brought her medical records, and they were thoroughly reviewed.  she currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in november of 2005.  she also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania.  medical records review a history of dysmenorrhea with surgery to the right cystic ovary.  the emdr did not benefit her in the past.  she also has not had good psychotherapeutic consultation.   diagnoses:axis  i.  309.81  posttraumatic stress disorder.    296.53  bipolar disorder, most recent episode depressed.      rule out 300.81 somatization disorder.axis  ii.  rule out 301.83 borderline personality disorder.axis iii.  history of ovarian cyst status-post surgery, migraine headaches. axis iv.  psychosocial stressors:  moderate.  she has problems with the primary support group, she is currently not speaking with her family, and just three days ago her husband was deployed to the theater of conflict.  she has economic issues, having difficulty living on base.  she has problems related to the social environment; she stated, &quot;i have no friends,&quot; identifying the only person in her life she can count on is being her husband.  axis v.    gaf:  55, current.  highest in the last year:  63. prognosis:  treatment treatment plan:  we discussed the diagnoses, somatization disorder, bipolar disorder, borderline personality disorder, and posttraumatic stress disorder.  we also discussed the treatment; we discussed emdr, as well as psychotherapy.  apparently, she has not had a full course of psychotherapy so she will be referred to lucy at counseling center.  we are going to take labs.  she is on trileptal and she will take an electrolyte profile for that.  we are going to wean her wellbutrin since it is not the best medication for posttraumatic stress disorder, and will replace it with an ssri.  the one chosen was lexapro.  she was given lunesta 3 mg p.o. q.h.s. to sleep.  we are starting lexapro 10 mg p.o. q.a.m.  she is also given ativan 1 mg p.o. t.i.d. p.r.n.  seroquel was decreased to 200 mg p.o. q.h.s., and trileptal will be started at 300 mg and eventually raised to 600 mg p.o. b.i.d.  old records will be reviewed from when they become available, and she will return for followup in approximately four weeks, which will be the middle of may."
+"<strong>procedure in detail: </strong>following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of vistaril 50 mg, atropine 0.4 mg im, and then intravenous medications of demerol 50 mg and versed 5 mg iv. perirectal inspection was normal. the olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. no abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum. retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure."
+"reason for consultation:  glioma. history of present illness:  the patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  she underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  she did well for the next 10 years or so, and developed parkinson disease, possibly related to radiation therapy.  she has been followed by neurology, dr. z, to treat seizure activity.  she has a vagal stimulator in place to help control her seizure activity. over the last few months, she has had increasing weakness on the right side.  she has been living in a nursing home.  she has not been able to walk, and she has not been able to write for the past three to four years. mri scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  there was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex. surgery was performed during this admission to remove some of the posterior part of the tumor.  she tolerated the procedure well.  she has noticed no worsening or improvement in her weakness.  pathology shows a low- to intermediate-grade glioma.  the second opinion by dr. a is still pending. the patient is feeling well today.  she is not having headache, and reports no new neurologic symptoms.  she has not had leg swelling, cough, shortness of breath, or chest pain. current medications:  1.  ambien p.r.n.  2.  vicodin p.r.n.  3.  actonel every sunday.  4.  colace.  5.  felbatol 1200 mg b.i.d.  6.  heparin injections for prophylaxis.  7.  maalox p.r.n.  8.  mirapex 0.5 mg t.i.d.  9.  protonix 40 mg daily.  10.  tylenol p.r.n.  11.  zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  12.  she has zofran p.r.n., albuterol inhaler q.i.d., and aggrenox, which she is to start. the rest of the history is mostly from the chart. allergies:  she is allergic to penicillin. past medical history:  1.  parkinson&#8217;s, likely secondary to radiation therapy.2.  history of prior stroke.3.  seizure disorder secondary to her brain tumor.4.  history of urinary incontinence.5.  she has had hip fractures x2, which have required surgical pinning.6.  appendectomy.7.  cholecystectomy. social history:  shows that she does not smoke cigarettes or drink alcohol.  she lives in a nursing home. family history:  shows a family history of breast cancer. physical examination:  general:  today, she is sitting up in the chair, alert, and appropriate.  she tends to lean towards the right.  the right arm and hand are noticeably weaker than the left.  she is quite thin.vital signs:  temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.heent:  there is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  the oropharynx shows no thrush or mucositis.lungs:  clear bilaterally to auscultation.cardiac:  exam shows regular rate.abdomen:  soft.extremities:  no peripheral edema or evidence of deep venous thrombosis (dvt) is noted on the lower extremities. impression and plan:  progressive low-grade glioma, now more than 20 years since initially diagnosed.  she is status post craniotomy for debulking and has done well with the surgery. we reviewed the phase ii trials that have used temodar in the setting of grade 2 gliomas.  although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  we discussed using temodar after she heals from her surgery.  toxicities would include fatigue, nausea, and myelosuppression primarily. the patient&#8217;s insurance is through securehorizons plan which we do not accept at our office, so i would discuss with dr. y setting her up to see another oncologist.  in the meantime, we can investigate the cost of temodar to her, i suspect she may have a 20% copay. she is anxious to have the foley catheter removed before she goes to her nursing home tomorrow.  she normally does not have a foley catheter in place.  orders have already been written by dr. y to have it removed."
+"preoperative diagnosis:  brain tumors, multiple. postoperative diagnoses:  brain tumors multiple &#8211; adenocarcinoma and metastasis from breast. procedure:  occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and cusa. procedure:  the patient was placed in the prone position after general endotracheal anesthesia was administered.  the scalp was prepped and draped in the usual fashion.  the cusa was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  the bone flap was elevated.  the ultrasound was then used.  the ultrasound showed the tumors directly i believe are in the interhemispheric fissure.  we noticed that the dura was quite tense despite that the patient had slight hyperventilation.  we gave 4 ounce of mannitol, the brain became more pulsatile.  we then used the stealth to perform a ventriculostomy.  once this was done, the brain began to pulsate nicely.  we then entered the interhemispheric space after we incised the dura in an inverted u fashion based on the superior side of the sinus.  after having done this we then used operating microscope and slight self-retaining retraction was used.  we obtained access to the tumor.  we biopsied this and submitted it.  this was returned as a malignant brain tumor &#8211; metastatic tumor, adenocarcinoma compatible with breast cancer. following this we then debulked this tumor using cusa and then removed it in total.  after gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  the next step was after removal of this tumor, closure of the wound, a large piece of duragen was placed over the dural defect and the bone flap was reapproximated and held secured with lorenz plates.  the tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  this being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  the next step was to close the wound after reapproximating the bone flap.  the galea was closed with 2-0 vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  the sterile dressings were applied to the scalp.  the patient returned to the recovery room in satisfactory condition.  hemodynamically remained stable throughout the operation. once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  the tumor was removed using the combination of cusa, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa."
+"spirometry:  spirometry reveals the fvc to be adequate. fev1 is also adequate 93% predicted.  fev1/fvc ratio is 114% predicted which is normal and fef25 75% is 126% predicted. after the use of bronchodilator, there is no significant improvement of the abovementioned parameters. mvv is also normal. lung volumes:  reveal a tlc to be 80% predicted.  frc is mildly decreased and rv is also mildly decreased.  rv/tlc ratio is also normal 97% predicted. diffusion capacity:  after correction for alveolar ventilation, is 112% predicted which is normal. oxygen saturation on room air:  98%. final interpretation:  pulmonary function test shows mild restrictive pulmonary disease.  there is no significant obstructive disease present.  there is no improvement after the use of bronchodilator and diffusion capacity is normal.  oxygen saturation on room air is also adequate.  clinical correlation will be necessary in this case."
+"diagnosis:  shortness of breath.  fatigue and weakness.  hypertension.  hyperlipidemia. indication:  to evaluate for coronary artery disease. test:  myocardial perfusion study at rest and stress, gated spect wall motion study at stress and calculation of ejection fraction. radiopharmaceutical:  technetium 99m and tetrofosmin. dose:  dose was 10.8mci at rest and 30.7mci at stress intravenous. description:  stress test was performed on bruce protocol for 5 minutes and 3 seconds. baseline heart rate was 75 bpm.  maximum heart rate was 98 bpm.  the patient did not achieve submax target heart rate.  stress test was nondiagnostic for ischemia. blood pressure response was flat during the stress test.  resting blood pressure was 138/78 reaching 130/80 at peak exercise.  the patient did not experience chest pain during exercise or post exercise.  resting ekg shows normal sinus rhythm with anteroseptal wall myocardial infarction, age undetermined, and nonspecific st-t changes.  nonspecific st-t changes at post exercise.  the ekg did not show st segment changes diagnostic for ischemia.  the patient had myocardial perfusion imaging performed using technetium 99m and tetrofosmin, 10.8mci at rest and 30.7mci at peak exercise.  imaging was performed using tomographic technique. finding:  the left ventricle was normal in size.  there was no myocardial perfusion defect noted. resting gated spect wall motion study reveals normal left ventricular wall motion with ejection fraction of 77%. regional wall motion was normal. impression:1.  normal myocardial perfusion study.2.  normal response to exercise.3.  normal left ventricular wall motion with ejection fraction of 77%.4.  resting right ventricular function was normal."
+"preoperative diagnosis:  brain tumor left temporal lobe. postoperative diagnosis:  brain tumor left temporal lobe &#8211; glioblastoma multiforme. operative procedure:1.  left temporal craniotomy.2.  removal of brain tumor. operating microscope:  stealth. procedure:  the patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  the entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  next, we made an inverted-u fashion base over the asterion over temporoparietal area of the skull.  a free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  the bone flap was placed aside and soaked in the bacitracin solution. the dura was then opened in an inverted-u fashion.  using the stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  we head through the vein of labbe, and we made great care to preserve this.  we saw where the tumor almost made to the surface.  here we made a small corticectomy using the stealth for guidance.  we left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  this was submitted to pathology.  we biopsied this very abnormal tissue and submitted it to pathology.  they gave us a frozen section diagnosis of glioblastoma multiforme.  with the operating microscope and greenwood bipolar forceps, we then systematically debulked this tumor.  it was very vascular and we really continued to remove this tumor until all visible tumors was removed.  we appeared to get two gliotic planes circumferentially.  we could see it through the ventricle.  after removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 nurolon sutures with the piece of duragen placed over this in order to increase our chances for a good watertight seal.  the bone flap was then replaced and sutured with the lorenz titanium plate system.  the muscle fascia galea was closed with interrupted 2-0 vicryl sutures.  skin staples were used for skin closure.  the blood loss of the operation was about 200 cc.  there were no complications of the surgery per se.  the needle count, sponge count, and the cottonoid count were correct. comment:  operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor &#8211; gliotic interface and while it was vague at sometimes we could i think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain."
+"chief complaint:  rule out obstructive sleep apnea syndrome. sample patient is a pleasant, 61-year-old, obese, african-american male with a past medical history significant for hypertension, who presents to the outpatient clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  he denies any gasping, choking, or coughing episodes while asleep at night.  his bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  he has two to three episodes of nocturia per night.  he denies any morning symptoms.  he has mild excess daytime sleepiness manifested by dozing off during boring activities. past medical history:  hypertension, gastritis, and low back pain. past surgical history:  turp. medications:  hytrin, motrin, lotensin, and zantac. allergies:  none. family history:  hypertension. social history:  significant for about a 20-pack-year tobacco use, quit in 1991.  no ethanol use or illicit drug use.  he is married.  he has one dog at home.  he used to be employed at budd automotors as a die setter for about 37 to 40 years. review of systems:  his weight has been steady over the years.  neck collar size is 17&frac12;&quot;.  he denies any chest pain, cough, or shortness of breath.  last chest x-ray within the past year, per his report, was normal. physical exam:  a pleasant, obese, african-american male in no apparent respiratory distress.  t:  98.  p:  90.  rr:  20.  bp:  156/90.  o2 saturation:  97% on room air.  ht:  5&#8242; 5&quot;.  wt:  198 lb.  heent:  a short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no jvd.  cardiac:  regular rate and rhythm without any adventitious sounds.  chest:  clear lungs bilaterally. abdomen:  an obese abdomen with active bowel sounds.  extremities:  no cyanosis, clubbing, or edema.  neurologic:  non-focal. impression:1.  probable obstructive sleep apnea syndrome.2.  hypertension.3.  obesity.4.  history of tobacco use. plan:1.  we will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.2.  encouraged weight loss.3.  check tsh.4.  asked not to drive and engage in any activity that could endanger himself or others while sleepy.5.  asked to return to the clinic one week after sleep the study is done."
+"name of procedure:  left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal. indication:  recurrent angina.  history of coronary disease. technical procedure:  standard judkins, right groin. catheters used:  6-french pigtail, 6-french jl4, 6-french jr4. anticoagulation:  2000 of heparin, 300 of plavix, was begun on integrilin. complications:  none. stent:  for stenting we used a 6-french left judkins guide.  stent was a 275 x 13 zeta. description of procedure:  i reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery.  all questions were answered and the patient decided to proceed. hemodynamic data:  aortic pressure was within physiologic range.  there was no significant gradient across the aortic valve. angiographic data1.  ventriculogram:  left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.2.  right coronary artery:  dominant.  there was a lesion in the proximal portion in the 60% range, insignificant disease distally.3.  left coronary artery:  the left main coronary artery showed insignificant disease.  the circumflex arose, showed about 30% proximally.  left anterior descending arose and the previously placed stent was perfectly patent.  there was a large diagonal branch which showed 90% stenosis in its proximal portion.  there was a lesion in the 30% to 40% range even more proximal. i reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery.  he desired that we intervene. successful stenting of the left anterior descending, diagonal.  the guide was placed in the left main.  we easily crossed the lesion in the diagonal branch of the left anterior descending.  we advanced, applied and post-dilated the 275 x 13 stent.  final angiography showed 0% residual at the site of previous 90% stenosis.  the more proximal 30% to 40% lesion was unchanged. conclusion1.  successful stenting of the left anterior descending/diagonal.  initially there was 90% in the diagonal after stenting.  there was 0% residual.  there was a lesion a bit more proximal in the 40% range.2.  left anterior descending stent remains patent.3.  30% in the circumflex.4.  60% in the right coronary.5.  ejection fraction and wall motion are normal. plan:  we have stented the culprit lesion.  the patient will receive a course of aspirin, plavix, integrilin, and statin therapy.  we used 6-french angio-seal in the groin.  all questions have been answered.  i have discussed the possibility of restenosis, need for further procedures."
+"reason for evaluation:  the patient is a 37-year-old white single male admitted to the hospital through the emergency room.  i had seen him the day before in my office and recommended him to go into the hospital.  he had just come from a trip to taho in nevada and he became homicidal while there.  he started having thoughts about killing his mother.  he became quite frightened by that thought and called me during the weekend we were able to see him on that tuesday after talking to him. history of present illness:  this is a patient that has been suffering from a chronic psychotic condition now for a number of years.  he began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  he was using drugs and smoking marijuana at that time has experimenting with lxv and another drugs too.  the patient has not used any drugs since age 25.  however, he has continued having intense and frequent psychotic bouts.  i have seen him now for approximately one year.  he has been quite refractory to treatment.  we tried different types of combination of medications, which have included clozaril, risperdal, lithium, and depakote with partial response and usually temporary.  the patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  the dosages that we have used have been very high.  he has been on clozaril 1200 mg combined with risperdal up to 9 mg and lithium at a therapeutic level.  however, he has not responded. he has delusions of antichrist.  he strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  he has paranoid delusions.  he also gets homicidal like prior to this admission. past psychiatric history:  as mentioned before, this patient has been psychotic off and on for about 20 years now.  he has had years in which he did better on clozaril and also his other medications. with typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout. past medical history:  he has a history of obesity and also of diabetes mellitus.  however, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking zyprexa.  the patient has chronic bronchitis.  he smokes cigarettes constantly up to 60 a day. drug history:  he stopped using drugs when he was 25.  he has got a lapse, but he was more than 10 years and he has been clean ever since then.  as mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis. psychosocial status:  the patient lives with his mother and has been staying with her for a few years now.  we have talked to her.  she is very supportive.  his only sister is also very supportive of him.  he has lived in the abcd houses in the past.  he has done poorly in some of them. mental status examination:  the patient appeared alert, oriented to time, place, and person.  his affect is flat.  he talked about auditory hallucinations, which are equivocal in nature.  he is not homicidal in the hospital as he was when he was at home.  his voice and speech are normal.  he believes in telepathy.  his memory appears intact and his intelligence is calculated as average. initial diagnoses:axis i:  schizophrenia.axis ii:  deferred.axis iii:  history of diabetes mellitus, obesity, and chronic bronchitis.axis iv:  moderate.axis v:  gaf of 35 on admission. initial treatment and plan:  since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  we will put him on benzodiazepines and make a decision anti-psychotic later.  we will make sure that he is safe and that he addresses his medical needs well."
+"<strong>procedure: </strong>fiberoptic bronchoscopy. <strong>preoperative diagnosis:</strong> right lung atelectasis. <strong>postoperative diagnosis:</strong> extensive mucus plugging in right main stem bronchus. <strong>procedure in detail:</strong> fiberoptic bronchoscopy was carried out at the bedside in the medical icu after versed 0.5 mg intravenously given in 2 aliquots. the patient was breathing supplemental nasal and mask oxygen throughout the procedure. saturations and vital signs remained stable throughout. a flexible fiberoptic bronchoscope was passed through the right naris. the vocal cords were visualized. secretions in the larynx were as aspirated. as before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. the ports were anesthetized and the trachea entered. there was no cough reflex helping explain the propensity to aspiration and mucus plugging. tracheal secretions were aspirated. the main carinae were sharp. however, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina. this was gradually lavaged clear. saline and mucomyst solution were used to help dislodge remaining plugs. the airways appeared slightly friable, but were patent after the airways were suctioned. o2 saturations remained in the mid-to-high 90s. the patient tolerated the procedure well. specimens were submitted for microbiologic examination. despite his frail status, he tolerated bronchoscopy quite well."
+"the tip of the endoscope was inserted in the rectum.  retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  the rest of the colon, through to the cecum, was well visualized.  the cecal strap and ileocecal valve were both identified.  there was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  adverse reactions none."
+"procedure performed:  esophagogastroduodenoscopy performed in the emergency department. indication:  melena, acute upper gi bleed, anemia, and history of cirrhosis and varices. final impression1.  scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.2.  endoscopy following erythromycin demonstrated grade i esophageal varices.  no stigmata of active bleeding.  small amount of fresh blood within the hiatal hernia.  no definite source of bleeding seen. plan1.  repeat egd tomorrow morning following aggressive resuscitation and transfusion.2.  proton-pump inhibitor drip.3.  octreotide drip.4.  icu bed. procedure details:  prior to the procedure, physical exam was stable.  during the procedure, vital signs remained within normal limits.  prior to sedation, informed consent was obtained.  risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  the patient was prepped in the left lateral position.  iv sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial egd.  an additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  scope tip of the olympus gastroscope was passed into the esophagus.  proximal, middle, and distal thirds of the esophagus were well visualized.  there was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  no evidence of varices was seen.  the stomach was entered.  the stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  there was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  because of this, the gastroscope was withdrawn.  the patient was given 250 mg of erythromycin in the emergency department and 30 minutes later, the scope was repassed.  on the second look, the esophagus was cleared.  the liquid gastric contents were cleared.  there was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  there was a small grade i esophageal varices, but no stigmata of bleed.  there was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  the patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  the scope was withdrawn and air was suctioned.  the patient tolerated the procedure well and was sent to recovery without immediate complications."
+"procedures performed:1.  left heart catheterization.2.  bilateral selective coronary angiography.3.  saphenous vein graft angiography.4.  left internal mammary artery angiography.5.  left ventriculography. indications:  persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000. procedure:  after the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  the patient was taken to the cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  once adequate anesthesia had been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right femoral artery.  a steel guidewire was then inserted through the needle into the vascular lumen without resistance.  a small nick was then made in the skin and its pressure was held.  the needle was removed over the guidewire.  a #6 french sheath was then advanced over the guidewire into the vascular lumen without resistance.  the guidewire and dilator were then removed.  the sheath was then flushed.  next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  the catheter was then advanced into the left ventricle.  the guidewire was then removed.  the catheter was connected to the manifold and flushed.  lvedp was then measured and found to be favorable for a left ventriculogram.  the left ventriculogram was performed in the rao position with a single power injection of non-ionic contrast material.  lvedp was then remeasured.  pullback was then performed, which failed to reveal an lvao gradient.  the catheter was then removed.  next, a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  once adequate study has been performed, the catheter was removed.  next, a judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  the saphenous vein graft was visualized in several different views.  the judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  right coronary system was evaluated in several different views.  once adequate study has been performed, the catheter was retracted.  we were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  next, a multipurpose catheter was advanced over the exchange wire.  the wire was then easily passed into the left subclavian artery.  the multipurpose catheter was then removed.  lima catheter was then exchanged over the wire into the left subclavian artery.  the guidewire was removed and the catheter was connected to the manifold and flushed.  lima graft was then engaged using hand injections of non-ionic contrast material.  the lima graft was evaluated in several different views.  once adequate study has been performed, the lima catheter was retracted under fluoroscopic guidance.  the sheath was flushed for the final time.  the patient was returned to the cardiac catheterization holding area in stable and satisfactory condition. findings:left ventriculogram:  there is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  left ventricular end-diastolic pressure was 24 mmhg preinjection and 26 mmhg postinjection.  there is no mitral regurgitation.  there is no lvao or pullback. left main coronary artery:  the left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  there is no evidence of any hemodynamically significant stenosis. left anterior descending artery:  the lad is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  there are luminal irregularities from the mid to distal portion.  there is noted to be antegrade flow in the lima to lad graft.  there are very small diagonal branches, which are diffusely diseased. circumflex artery:  the circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  there are minor luminal irregularities throughout.  there are very small obtuse marginal branches, which are diffusely diseased. right coronary artery:  the rca is a small vessel with luminal irregularities throughout.  the rca is the dominant coronary artery. left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  saphenous vein graft to the obtuse marginal branches is a y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  the saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease. impression:1.  diffusely diseased native vessels.2.  saphenous vein graft to the obtuse marginal branch is widely patent.3.  left internal mammary artery graft to the left anterior descending artery is patent.4.  normal left ventricular function with ejection fraction of 60%.5.  mildly elevated left-sided filling pressures. plan:1.  the patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and plavix.  the patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.2.  we will add norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.3.  risk factor modification was discussed with the patient including diet control as well as tobacco cessation.4.  the patient will need to be monitored closely for close lipid control as well as blood pressure control."
+time seen:  0734 hours and 1034 hours. total recording time:  27 hours 4 minutes. patient history:  this is a 43-year-old female with a history of events concerning for seizures.  video eeg monitoring is performed to capture events and/or identify etiology. video eeg diagnoses1.  awake:  normal.2.  sleep:  no activation.3.  clinical events:  none. description:  approximately 27 hours of continuous 21-channel digital video eeg monitoring was performed.  the waking background is unchanged from that previously reported.  hyperventilation produced no changes in the resting record.  photic stimulation failed to elicit a well-developed photic driving response. approximately five-and-half hours of spontaneous intermittent sleep was obtained.  sleep spindles were present and symmetric. the patient had no clinical events during the recording. clinical interpretation:  this is normal video eeg monitoring for a patient of this age.  no interictal epileptiform activity was identified.  the patient had no clinical events during the recording.  clinical correlation is required.
+"procedure:  esophagogastroduodenoscopy with biopsy. preoperative diagnosis:  a 1-year-10-month-old with a history of dysphagia to solids.  the procedure was done to rule out organic disease. postoperative diagnoses:  loose lower esophageal sphincter and duodenal ulcers. consent:  the consent is signed. medications:  the procedure was done under general anesthesia given by dr. marino fernandez. complications:  none. procedure in detail:  a history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure.  the opportunity for questions was provided, and informed consent was obtained.  once the consent was obtained, the patient was sedated with iv medications and intubated by dr. fernandez and placed in the supine position.  then, the tip of the xp-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus.  we did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose.  then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum.  we noticed that the patient had several ulcers in the first portion of the duodenum.  then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there.  then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for clotest.  by retroflexed view, at the level of the body of the stomach, i could see that the patient had the lower esophageal sphincter loose.  finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken.  at the end, air was suctioned from the stomach, and the endoscope was removed out of the patient&#8217;s mouth.  the patient tolerated the procedure well with no complications. final impression:  1.  duodenal ulcers.2.  loose lower esophageal sphincter. plan:1.  to start omeprazole 20 mg a day.2.  to review the biopsies.3.  to return the patient back to clinic in 1 to 2 weeks."
+"angina is chest pain due to a lack of oxygen to the heart most often occurring in men age 35 or older and postmenopausal women.  it is usually located right under the breast bone.  physical and emotional stress, as well as eating heavy meals, can bring it on.  in a healthy person, these stresses are easily handled.  in a person with an underlying heart condition like coronary artery disease, heart valve problem, arrhythmias or high blood pressure, the heart doesn&#8217;t get enough blood (i.e. not enough oxygen to the heart muscles).  other causes could be due to a hyperactive thyroid disorder or anemia.  people more likely to have angina may also have diabetes mellitus, be overweight, smoke, have a poor diet with lots of salt and fat, fail to exercise, have a stressful workload or have a family history of coronary artery disease. signs and symptoms:*  pain in chest described as tightness, heavy pressure, aching or squeezing.*  the pain sometimes radiates to the jaw, left arm, teeth and/or outer ear.*  possibly a left-sided numbness, tingling, or pain in the arm, shoulder, elbow or chest.*  occasionally a sudden difficulty in breathing occurs.*  pain may be located between the shoulder blades. treatment:*  nitroglycerin relieves the immediate symptoms of angina in seconds.  carry it with you at all times.*  other medications may be prescribed for the underlying heart problems.  it is important to take them as prescribed by your doctor.*  surgery may be necessary to open the blocked coronary arteries (balloon angioplasty) or to bypass them.*  correct the contributing factors you have control over.  lose weight, don&#8217;t smoke, eat a low-salt, low-fat diet and avoid physical and emotional stresses that cause angina.  such stressors include anger, overworking, going between extremes in hot and cold, sudden physical exertion and high altitudes (pressurized airplanes aren&#8217;t a risk).  practice relaxation techniques.*  exercise! discuss first what you are able to do with your doctor and then go do it.*  even with treatment, angina may result in a heart attack, congestive heart failure or a fatal abnormal heartbeat.  treatment decreases the odds that these will occur.*  let your doctor know if your angina doesn&#8217;t go away after 10 minutes, even when you have taken a nitroglycerin tablet.  call if you have repeated chest pains that awaken you from sleep regardless if the nitroglycerin helps.  if your pain changes or feels different, call your doctor or call 911 if the pain is severe."
+"history of present illness: the patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when i first saw him in the office on 01/11/06. he is now 77 years old. he is being seen on the seventh floor. the patient is in room 7607. the patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. the workup began with gi bleeding. he was seen in my office on 01/11/06 for preop evaluation due to leg edema. a nonocclusive dvt was diagnosed in the proximal left superficial femoral vein. both legs were edematous, and bilateral venous insufficiency was also present. an echocardiogram demonstrated an ejection fraction of 50%. the patient was admitted to the hospital and treated with a greenfield filter since anticoagulant was contraindicated. additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. the rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. there was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. the ejection fraction was considered low normal, since it was estimated 50 to 54%. the patient received blood while in the hospital due to anemia. the leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. the patient, who was diabetic, received consultation by dr. r. he was also a chronic hypertensive and was treated for that with ace inhibitors. the atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. as a matter of fact, they were discontinued. now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia. allergies: the patient has no known drug allergies. his diabetes was suspected to be complicated with neuropathy due to tingling in both feet. he received his immunizations with flu in 2005 but did not receive pneumovax. social history: the patient is married. he had 1 child who died at the age of 26 months of unknown etiology. he quit smoking 6 years ago but dips (smokeless) tobacco. family history: mother had cancer, died at 70. father died of unknown cause, and brother died of unknown cause. functional capacity: the patient is wheelchair bound at the time of his initial hospitalization. he is currently walking in the corridor with assistance. nocturia twice to 3 times per night. review of systems:ophthalmologic: uses glasses.ent: complains of occasional sinusitis.cardiovascular: hypertension and atrial fibrillation.respiratory: normal.gi: colon bleeding. the patient believes he had ulcers.genitourinary: normal.musculoskeletal: complains of arthritis and gout.integumentary: edema of ankles and joints.neurological: tingling as per above. denies any psychiatric problems.endocrine: diabetes, niddm.hematologic and lymphatic: the patient does not use any aspirin or anticoagulants and is not of anemia. laboratory: current ekg demonstrates atrial fibrillation with incomplete left bundle branch block pattern. q waves are noticed in the inferior leads. nonprogression of the r-wave from v1 to v4 with small r-waves in v5 and v6 are suggestive of an old anterior and inferior infarcts. left ventilator hypertrophy and strain is suspected. physical examination:general: on exam, the patient is alert, oriented and cooperative. he is mildly pale. he is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.vital signs: blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. pulse oximetry is 100.neck: without jvd, bruit, or thyromegaly. the neck is supple.chest: symmetric. there is no heave or retraction.heart: the heart sounds are irregular and no significant murmurs could be auscultated.lungs: clear to auscultation.abdomen: exam was deferred.legs: without edema. pulses: dorsalis pedis pulse was palpated bilaterally. medications: current medications include enalapril, low dose enoxaparin, fentanyl patches. he is no longer on fluconazole. he is on a sliding scale as per dr. holden. he is on lansoprazole (prevacid), toradol, piperacillin/tazobactam, hydralazine p.r.n., zofran, dilaudid, benadryl, and lopressor p.r.n. assessment and plan: the patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. his cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. he has chronic atrial fibrillation. i do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. he is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. reason being is high likelihood for gi bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. at this point, i agree with the notion of hospice care. if his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, i would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers."
+"indications for procedure: the patient has presented with atypical type right arm discomfort and neck discomfort. she had noninvasive vascular imaging demonstrating suspected right subclavian stenosis. of note, there was bidirectional flow in the right vertebral artery, as well as 250 cm per second velocities in the right subclavian. duplex ultrasound showed at least a 50% stenosis. approach: right common femoral artery. anesthesia: iv sedation with cardiac catheterization protocol. local infiltration with 1% xylocaine. complications: none. estimated blood loss: less than 10 ml. estimated contrast: less than 250 ml. procedure performed: right brachiocephalic angiography, right subclavian angiography, selective catheterization of the right subclavian, selective aortic arch angiogram, right iliofemoral angiogram, 6 french angio-seal placement. description of procedure: the patient was brought to the cardiac catheterization lab in the usual fasting state. she was laid supine on the cardiac catheterization table, and the right groin was prepped and draped in the usual sterile fashion. 1% xylocaine was infiltrated into the right femoral vessels. next, a #6 french sheath was introduced into the right femoral artery via the modified seldinger technique. aortic arch angiogram: next, a pigtail catheter was advanced to the aortic arch. aortic arch angiogram was then performed with injection of 45 ml of contrast, rate of 20 ml per second, maximum pressure 750 psi in the 4 degree lao view. selective subclavian angiography: next, the right subclavian was selectively cannulated. it was injected in the standard ap, as well as the rao view. next pull back pressures were measured across the right subclavian stenosis. no significant gradient was measured. angiographic details: the right brachiocephalic artery was patent. the proximal portion of the right carotid was patent. the proximal portion of the right subclavian prior to the origin of the vertebral and the internal mammary showed 50% stenosis. impression:1. moderate grade stenosis in the right subclavian artery.2. patent proximal edge of the right carotid."
+"discharge diagnoses:1.  bilateral lower extremity cellulitis secondary to bilateral tinea pedis.2.  prostatic hypertrophy with bladder outlet obstruction.3.  cerebral palsy. discharge instructions:  the patient would be discharged on his usual valium 10-20 mg at bedtime for spasticity, flomax 0.4 mg daily, cefazolin 500 mg q.i.d., and lotrimin cream between toes b.i.d. for an additional two weeks.  he will be followed in the office. history of present illness:  this is a pleasant 62-year-old male with cerebral palsy.  the patient was recently admitted to hospital with lower extremity cellulitis.  this resolved, however, recurred in both legs.  examination at the time of this admission demonstrated peeling of the skin and excoriation between all of his toes on both feet consistent with tinea pedis. past medical/family/social history:  as per the admission record. review of systems:  as per the admission record. physical examination:  as per the admission record. laboratory studies:  at the time of admission, his white blood cell count was 8200 with a normal differential, hemoglobin 13.6, hematocrit 40.6 with normal indices, and platelet count was 250,000.  comprehensive metabolic profile was unremarkable, except for a nonfasting blood sugar of 137, lactic acid was 0.8.  urine demonstrated 4-9 red blood cells per high-powered field with 2+ bacteria.  blood culture and wound cultures were unremarkable.  chest x-ray was unremarkable. hospital course:  the patient was admitted to the general medical floor and treated with intravenous ceftriaxone and topical lotrimin.  on this regimen, his lower extremity edema and erythema resolved quite rapidly. because of urinary frequency, a bladder scan was done suggesting about 600 cc of residual urine.  a foley catheter was inserted and was productive of approximately 500 cc of urine.  the patient was prescribed flomax 0.4 mg daily.  24 hours later, the foley catheter was removed and a bladder scan demonstrated 60 cc of residual urine after approximately eight hours. at the time of this dictation, the patient was ambulating minimally, however, not sufficiently to resume independent living."
+"medications:1.  versed intravenously.2.  demerol intravenously. description of the procedure:  after informed consent, the patient was placed in the left lateral decubitus position and cetacaine spray was applied to the posterior pharynx.  the patient was sedated with the above medications.  the olympus video panendoscope was advanced under direct vision into the esophagus.  the esophagus was normal in appearance and configuration.  the gastroesophageal junction was normal.  the scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  the gastric mucosa appeared normal.  the pylorus was normal.  the scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  the scope was pulled back into the stomach.  retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  the scope was straightened out, the air removed and the scope withdrawn.  the patient tolerated the procedure well.  there were no apparent complications."
+"exam:  cta chest pulmonary angio. reason for exam:  evaluate for pulmonary embolism. technique:  postcontrast ct chest pulmonary embolism protocol, 100 ml of isovue-300 contrast is utilized. findings:  there are no filling defects in the main or main right or left pulmonary arteries.  no central embolism.  the proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  there is no evidence of a central embolism. as seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  however, there is considerable change in the appearance of the lung fields.  there are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  there are also extensive right lung consolidations, all new or increased significantly from the prior examination.  again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  there is no pneumothorax in the interval. on the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  there is aortic root and arch and descending thoracic aortic calcification.  there are scattered regions of soft plaque intermixed with this.  the heart is not enlarged.  the left axilla is intact in regards to adenopathy.  the inferior thyroid appears unremarkable. limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  spleen, adrenal glands, and upper kidneys appear unremarkable.  visualized portions of the pancreas are unremarkable. there is extensive rib destruction in the region of the chest wall mass.  there are changes suggesting prior trauma to the right clavicle. impression:1.  again demonstrated is a large right chest wall mass.2.  no central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.3.  new bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.4.  see above regarding other findings."
+"preoperative diagnoses:1.  ischemic cardiomyopathy.2.  status post redo coronary artery bypass.3.  status post insertion of intraaortic balloon. postoperative diagnoses:1.  ischemic cardiomyopathy.2.  status post redo coronary artery bypass.3.  status post insertion of intraaortic balloon.4.  postoperative coagulopathy. operative procedure:1.  orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.2.  open sternotomy covered with ioban.3.  insertion of mahurkar catheter for hemofiltration via the left common femoral vein. anesthesia:  general endotracheal. operative procedure:  with the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  a right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  a sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  the patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  a percutaneous catheter for arterial return was placed using seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  after satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  after the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  a cardiectomy was then performed by starting in the right atrium.  the wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the swan-ganz catheter was brought out into the operative field.  cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  the right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  first, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 prolene suture.  the pulmonary artery was then anastomosed using 5-0 prolene and the aorta was anastomosed with 4-0 prolene.  the arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  air was evacuated and the sutures were tied down.  the clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  the patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  blood factors and factor vii were given to try and correct the coagulopathy.  because of excessive transfusions that were required, a mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the mahurkar catheter was then placed with 2-0 nylon suture.  hemofiltration was started in the operating room at this time.  after he had satisfactory hemostasis, we decided to do the chest open and cover it with ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  the patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  this was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  the patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor vii.  urine output for the procedure was 520 ml.  the preservation time of the heart is in the anesthesia sheet.  the estimated blood loss was at least 6 l.  the patient was taken to the intensive care unit in guarded condition."
+"cc:  &quot;five years ago, i stopped drinking and since that time, i have had severe depression.  i was doing okay when i stopped my medications in april for a few weeks, but then i got depressed again.  i started lithium three weeks ago.&quot; hpi:  the patient is a 45-year-old married white female without children currently working as a billing analyst for northwest natural.  the patient has had one psychiatric hospitalization for seven days in april of 1999.  the patient now presents with recurrent depressive symptoms for approximately four months.  the patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite.  the patient states her sleep is normal and her ability to concentrate is normal.  the patient states that last night she had an argument with her husband in which he threaten to divorce her.  the patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth.  she felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done.  the patient reports that she has had increased tension with her husband as of recent.  she notes that approximately a week ago she struck her husband several times.  she states that he has never hit her but instead pushed her back after she was hitting him.  she reports no history of abuse in the past.  the patient identifies recent stressors as having ongoing conflict at work with her administrator with them &quot;cracking down on me.&quot; the patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child.  she states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant.  the patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment.  she states that she feels &quot;abandoned.&quot; the patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband.  the patient states she saw her therapist most recently last friday.  she sees the therapy weekly and indicates the therapy helps, although she is unable to specify how.  when asked for specifics of what she has learned from the therapy, the patient was unable to reply.  it appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation.  the patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization.  the patient, at that point, stated that she would be safe through monday despite having made a gesture last night.  at present, the patient&#8217;s mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after i have given her my assessment, she appears calmed and not depressed.  when asked if she is suicidal at present, she states no.  the patient does not want to go into the hospital.  the patient also indicates at the end of the session she felt hopeful.  the patient reports her current sleep is about eight hours per night.  she states that longest she has been able to stay awake in the past has been 24 hours.  she states that during periods where she feels up she sleeps perhaps six hours per night.  the patient reports no spending sprees and no reports no sexual indiscretions.  the patient states that her sexuality does increase when she is feeling better but not enormously so.  the patient denies any history of delusions or hallucinations.  the patient denies any psychosis.  the patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest.  she states that more predominately she has depression.  the patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so.  the patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment.  the patient indicates some satisfaction when she is called on her behavior &quot;i need to answer for my actions.&quot; the patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized.  most typically, the patient will drink at least a bottle of wine per day.  the patient has attended aa but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility.  the patient states she is not working through any of the steps at present. pph:  the patient denies any sexual abuse as a child.  she states that she was disciplined primarily by her father with spankings.  she states that on occasion her mother would use a belt to spank her or with her hand or with a spoon.  the patient has been seeing dr. a for the past five years.  prior to that she was admitted to a hospital for her suicide attempt.  the patient also has one short treatment experienced with the day treatment program here in portland.  the patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with.  the patient, also as a child, had a history of cutting behaviors.  the patient was admitted to the hospital after lacerating her arm. medical history:  the patient has hypothyroidism and last had her tsh drawn a week ago but does not know the results.  janet green is her primary physician.  the patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically. current medications:  the patient currently is taking synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. the patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test. allergies:  no known drug allergies. substance history:  the patient has been sober for five years.  she drank one bottle of wine per day as per hpi.  history of drinking for approximately 25 years.  the patient does not currently have a sponsor.  the patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago. social history:  the patient&#8217;s mother is age 66, father is age 70, and she has a brother age 44.  her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage.  he made a suicide attempt at age 17.  the patient&#8217;s father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem.  he also has arthritis.  the patient&#8217;s mother is arthritic.  she states that her mother stopped working at middle age after being laid off and appears somewhat reclusive. educational history:  the patient was educated through high school and has two years of night college.  the patient states that she grew up and was raised in portland but notes her childhood was primarily lonely.  she states she was unliked and unpopular child because she was &quot;shy&quot; and &quot;not smart enough.&quot; the patient denies having secrets.  the patient reports that this is her second marriage, which has lasted two years.  her first marriage lasted i believe it was five years.  the patient also had a relationship in recovery for four years, which ended after they went &quot;different directions.&quot; mse:  the patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals.  the patient is suspicious and somewhat confrontative early in the session.  she asked me regarding my cancellation policy, why i require seven days and not 24 hours.  the patient also is irritated with paper required of her.  psychomotor is increased slightly.  the patient makes strong eye contact.  speech is normal rate, rhythm, and volume.  mood is &quot;irritated.&quot; affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated.  thought is directed.  content is nondelusional.  there are no auditory and no visual hallucinations.  the patient has no homicidal ideation.  the patient does endorse suicidal ideations.  regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none.  the patient states that she will not try to hurt herself currently and that she poses no risk at present.  the patient notes that she does not want to go to the hospital at present.  the patient is alert and oriented x 3.  recall is three for three at five minutes.  proverbs are concrete.  she has fair impulse control, poor judgment, and poor insight. formulation:  the patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning.  the patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression.  the patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states.  the patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant.  she notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets.  the patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy.  the patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter.  symptoms are consistent with a longstanding dysthymia and reoccurring depression.  in addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder.  this latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist&#8217;s absence and departure.  this is exacerbated by instability in the patient&#8217;s marital life. diagnosis:axis i:  dysthymia.  major depression, moderate severity, recurrent, with partial remission.axis ii:  borderline personality disorder.axis iii:  hypothyroidism and cervical disc herniation and sinus surgery.axis iv:  medical access.  marital discord.axis v:  a gaf of 30. plan:  the patient is unlikely to have bipolar disorder.  we will recommend the patient&#8217;s thyroid be rechecked to ensure she is currently euthymic.  we would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient&#8217;s reaction to her therapist&#8217;s departure.  we would also recommend dialectical behavioral therapy while the therapist is on leave.  we would recommend continued treatment with ssris for dysthymia and depression.  we would suggest prescribing long acting antidepressant such as prozac, given the patient&#8217;s ambivalence regarding medications.  prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg.  we might also supplement the prozac with a (anti-sleep medication). time spent with the patient was 1.5 hours."
+"cc: memory difficulty. hx: this 64 y/o rhm had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. this had been called to his attention by the clerical staff at his parish&#8211;he was a catholic priest. he had had no professional or social faux pas or mishaps due to his memory. he could not tell whether his problem was becoming worse, so he brought himself to the neurology clinic on his own referral. meds: none. pmh: 1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs. fhx: both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. there are no neurological illnesses in his family. shx: catholic priest. denied tobacco/etoh/illicit drug use. exam:  bp131/74, hr78, rr12, 36.9c, wt. 77kg, ht. 178cm. ms: a&#038;o to person, place and time. 29/30 on mmse; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. unable to remember the name of the president (clinton). 23words/60 sec on category fluency testing (normal). mild visual constructive deficit. the rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted. course: tsh 5.1, t4 7.9, rpr non-reactive. neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. the findings indicated multiple areas of cerebral dysfunction. with the exception of the patient&#8217;s report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as alzheimer&#8217;s disease. mri brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions. in 4/96, his performance on repeat neuropsychological evaluation was relatively stable. his verbal learning and delayed recognition were within normal limits, whereas delayed recall was &quot;moderately severely&quot; impaired. immediate and delayed visual memory were slightly below expectations. temporal orientation and expressive language skills were below expectation, especially in word retrieval. these findings were suggestive of particular, but not exclusive, involvement of the temporal lobes. on 9/30/96, he was evaluated for a 5 minute spell of visual loss, ou. the episode occurred on friday, 9/27/96, in the morning while sitting at his desk doing paperwork. he suddenly felt that his gaze was pulled toward a pile of letters; then a &quot;curtain&quot; came down over both visual fields, like &quot;everything was in the shade.&quot; during the episode he felt fully alert and aware of his surroundings. he concurrently heard a &quot;grating sound&quot; in his head. after the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. he then drove to visit his sister in muscatine, iowa, without accident. he was reportedly &quot;normal&quot; when he reached her house. he was able to perform mass over the weekend without any difficulty. neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)vfftc and eom were intact. there was no rapd, ino, loss of visual acuity. glucose 178 (elevated), esr ,lipid profile, gs, cbc with differential, carotid duplex scan, ekg, and eeg were all normal. mri brain, 9/30/96, was unchanged from previous, 3/6/95. on 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. the episode was felt due to orthostatic changes. 1/8/97 neuropsychological evaluation was stable and his mmse score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). category fluency score 23 items/60 sec. neurologic exam was notable for graphesthesia in the left hand. in 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. his neurologic exam was unchanged. an fdg-pet scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions."
+"cc: decreasing visual acuity. hx: this 62 y/o rhf presented locally with a 2 month history of progressive loss of visual acuity, od. she had a 2 year history of progressive loss of visual acuity, os, and is now blind in that eye. she denied any other symptomatology. denied ha. pmh: 1) depression. 2) blind os meds: none. shx/fhx: unremarkable for cancer, cad, aneurysm, ms, stroke. no h/o tobacco or etoh use. exam: t36.0, bp121/85, hr 94, rr16 ms: alert and oriented to person, place and time. speech fluent and unremarkable. cn: pale optic disks, ou. visual acuity: 20/70 (od) and able to detect only shadow of hand movement (os). pupils were pharmacologically dilated earlier. the rest of the cn exam was unremarkable. motor: 5/5 throughout with normal bulk and tone. sensory: no deficits to lt/pp/vib/prop. coord: fnf-ram-hks intact bilaterally. station: no pronator drift. gait: nd reflexes: 3/3 bue, 2/2 ble. plantar responses were flexor bilaterally. gen exam: unremarkable. no carotid/cranial bruits. course: ct brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. mri brain findings were consistent with an aneurysm. the patient underwent 3 vessel cerebral angiogram on 12/29/92. this clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. emergent hct showed no evidence of hemorrhage or sign of infarct. emergent carotid duplex showed no significant stenosis or clot. the patient was left with an expressive aphasia and right hemiparesis. spect scans were obtained on 1/7/93 and 2/24/93. they revealed hypoperfusion in the distribution of the left mca and decreased left basal-ganglia perfusion which may represent in part a mass effect from the lica aneurysm. she was discharged home and returned and underwent placement of a selverstone clamp on 3/9/93. the clamp was gradually and finally closed by 3/14/93. she did well, and returned home. on 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. a hct then showed sah around her aneurysm, which had thrombosed. she was place on nimodipine. her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. an emergent hct demonstrated a left aca and left mca infarction. she required intubation and worsened as cerebral edema developed. she was pronounced brain dead. her organs were donated for transplant."
+"cc: falling. hx: this 67y/o rhf was diagnosed with parkinson&#8217;s disease in 9/1/95, by a local physician. for one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. she also noticed that she was slowly &quot;losing&quot; her voice, and that her handwriting was becoming smaller and smaller. two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. she noted no improvement on sinemet, which was started in 9/95. at the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. she felt weak in the morning and worse as the day progressed. she denied any fever, chills, nausea, vomiting, ha, change in vision, seizures or stroke like events, or problems with upper extremity coordination. meds: sinemet cr 25/100 1tab tid, lopressor 25mg qhs, vitamin e 1tab tid, premarin 1.25mg qd, synthroid 0.75mg qd, oxybutynin 2.5mg has, isocyamine 0.125mg qd. pmh: 1) hysterectomy 1965. 2) appendectomy 1950&#8242;s. 3) left ctr 1975 and right ctr 1978. 4) right oophorectomy 1949 for &quot;tumor.&quot; 5) bladder repair 1980 for unknown reason. 6) hypothyroidism dx 4/94. 7) htn since 1973. fhx: father died of mi, age 80. mother died of mi, age73. brother died of brain tumor, age 9. shx: retired employee of champion automotive co. denies use of tob/etoh/illicit drugs. exam: bp (supine)182/113 hr (supine)94. bp (standing)161/91 hr (standing)79. rr16 36.4c. ms: a&#038;o to person, place and time. speech fluent and without dysarthria. no comment regarding hypophonia. cn: pupils 5/5 decreasing to 2/2 on exposure to light. disks flat. remainder of cn exam unremarkable. motor: 5/5 strength throughout. no tremor noted at rest or elicited upon movement or distraction sensory: unremarkable pp/vib testing. coord: did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. there was mild decrement on finger tapping and clasping/unclasping hands (right worse than left). gait: slow gait with difficulty turning on point. difficulty initiating gait. there was reduced bue swing on walking (right worse than left). station: 3-4step retropulsion. reflexes: 2/2 and symmetric throughout bue and patellae. 1/1 achilles. plantar responses were flexor. gen exam: inremarkable. heent: unremarkable. course: the patient continued sinemet cr 25/100 1tab tid and was told to monitor orthostatic bp at home. the evaluating neurologist became concerned that she may have parkinsonism plus dysautonomia. she was seen again on 5/28/96 and reported no improvement in her condition. in addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. there were no involuntary movements or alteration in sensorium/mental status. during the episode she recalled wanting to turn, but could not. two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. she discontinued sinemet 5 days prior to 5/28/96 and felt better. she felt she was moving slower and that her micrographia had worsened. she had had recent difficulty rolling over in bed and has occasional falls when turning. she denied hypophonia, dysphagia or diplopia. on exam: bp (supine)153/110 with hr 88. bp (standing)110/80 with hr 96. (+) myerson&#8217;s sign and mild hypomimia, but no hypophonia. there was normal blinking and eom. motor strength was full throughout. no resting tremor, but mild postural tremor present. no rigidity noted. mild decrement on finger tapping noted. reflexes were symmetric. no babinski signs and no clonus. gait was short stepped with mild anteroflexed posture. she was unable to turn on point. 3-4 step retropulsion noted. the parkinsonism had been unresponsive to sinemet and she had autonomic dysfunction suggestive of shy-drager syndrome. it was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. indomethacin was suggested to improve bp in future."
+"preoperative diagnosis:  positive peptic ulcer disease. postoperative diagnosis:  gastritis. procedure performed:  esophagogastroduodenoscopy with photography and biopsy. gross findings:  the patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease. upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  the profundus and the cardia of the stomach were unremarkable.  the pylorus was concentric.  the duodenal bulb and sweep with no inflammation, tumors, or masses. operative procedure:  the patient taken to the endoscopy suite, prepped and draped in the left lateral decubitus position.  she was given iv sedation using demerol and versed.  olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  the above gross findings noted.  the panendoscope was withdrawn back from the stomach, deflected upon itself.  the lesser curve fundus and cardiac were well visualized.  upon examination of these areas, panendoscope was returned to midline.  photographs and biopsies were obtained of the antrum of the stomach.  air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel. photographs and biopsies were obtained as appropriate.  the patient is sent to recovery room in stable condition."
+"<strong>preoperative diagnosis:</strong> airway stenosis with self-expanding metallic stent complication. <strong>postoperative diagnosis:</strong> airway stenosis with self-expanding metallic stent complication. <strong>procedures:</strong> 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. <strong>endoscopic findings:</strong> 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. <strong>technique in detail: </strong>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."
+"preoperative diagnosis:  antibiotic-associated diarrhea.   postoperative diagnosis:  antibiotic-associated diarrhea.   operation performed:  colonoscopy with random biopsies and culture. indications:  the patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  she has been having difficulty since that time with intermittent diarrhea and abdominal pain.  she states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  she presents today for screening colonoscopy, based on the same. operative course:   the risks and benefits of colonoscopy were explained to the patient in detail.  she provided her consent.  the morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  she was placed in the left lateral decubitus position.  in divided doses, she was given 7 mg of versed and 125 mcg of fentanyl.  a digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  this was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  in truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  while more medication could have been given, the patient is actually a fairly thin woman and diminutive and i was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  in addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  for this reason, the procedure was aborted at the level of the hepatic flexure.  she was noted to have some pools of stool.  this was suctioned and sent to pathology for c difficile, ova and parasites, and fecal leukocytes.  additionally, random biopsies were performed of the colon itself.  it is unfortunate we were unable to complete this procedure, as i would have liked to have taken biopsies of the terminal ileum.  however, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, i am very suspicious of irritable bowel syndrome.  the patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home. plan:  she needs to follow up with me in approximately 2 weeks&#8217; time, both to follow up with her biopsies and cultures.  she has been given a prescription for vsl3, a probiotic, to assist with reculturing the rectum.  she may also benefit from an antispasmodic and/or anxiolytic.  lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated."
+"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."
+"preoperative diagnoses:1.  gastroesophageal reflux disease.2.  hiatal hernia. postoperative diagnoses:1.  gastroesophageal reflux disease.2.  hiatal hernia.3.  enterogastritis. procedure performed:  esophagogastroduodenoscopy, photography, and biopsy. gross findings:  the patient has a history of epigastric abdominal pain, persistent in nature.  she has a history of severe gastroesophageal reflux disease, takes pepcid frequently.  she has had a history of hiatal hernia.  she is being evaluated at this time for disease process.  she does not have much response from protonix. upon endoscopy, the gastroesophageal junction is approximately 40 cm.  there appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  there is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  however there appeared to be inflammation as stated previously in the gastroesophageal junction.  there was some mild inflammation at the antrum of the stomach.  the fundus of the stomach was within normal limits.  the cardia showed some laxity to the lower esophageal sphincter.  the pylorus is concentric.  the duodenal bulb and sweep are within normal limits.  no ulcers or erosions. operative procedure:  the patient is taken to the endoscopy suite, prepped and draped in the left lateral decubitus position.  the patient was given iv sedation using demerol and versed.  olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  photographs were taken with the pathology present.  biopsy was obtained of the antrum of the stomach and also clo test.  the biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o&#8217; clock positions to rule out occult barrett&#8217;s esophagitis.  air was aspirated from the stomach and the panendoscope was removed.  the patient sent to recovery room in stable condition."
+"indication:      recurrent dysphagia. premedications:  see procedure nurse ncs form.  procedure:  consent par conference was held.  after signing the informed consent, premedications were given.  the patient was placed in the left lateral decubitus position and monitored with blood pressure cuff and pulse oximeter throughout the procedure.  hurricaine spray was placed in the back of the throat.  the olympus endoscope was passed under direct visualization through the cricopharyngeus into the esophageal area.  it was passed through the esophagus with identification of the eg junction and into the stomach.  a portion of the stomach and the rugal folds were visualized.  the scope was passed into the antral area with visualization of the pylorus.  the pylorus was cannulated and the duodenal bulb and the second position of the duodenum were visualized.  the scope was passed back into the stomach where the cardia, fundus, and lesser curvature were visualized in a retrograde manner.  the following findings were noted:   findings:  1.  the esophagus was significantly tortuous and somewhat shortened with a large hiatal hernia with the eg junction at approximately 30 cm.  it was difficult to tell if there was significant narrowing in the esophagus with the significant tortuosity and the scope passing into the stomach.  no resistance was noted to the endoscope.2.  the stomach was abnormal with a very large sliding type hiatal hernia.3.  the duodenum was normal.4.  a savary wire was placed in the antrum and the scope was removed.  positioning the wire by markings, a #14 french dilator was passed without difficulty into the stomach area.  there was some resistance to a #16 french dilator, although at that time it had passed to approximately 40 cm and i suspect we were through the eg junction area.  this may have been curling in the hiatal hernia, i opted not to use further force to advance the dilator further. the scope was removed and the patient tolerated the procedure well.   impression:  very large hiatal hernia and tortuous esophagus, probably with mild peptic stricture, dilated to #14 french.  i may even have gotten the #16 french dilator through, but it was not passed all the way into the stomach area because of some resistance which i suspect was curling in the hiatal hernia. plan:  i will have her follow up with my nurse practitioner in approximately 10 days.  if her dysphagia is improved, we will simply observe.  if she continues to have dysphagia, we will bring her back and attempt to re-dilate her with a #15 french dilator.  she will continue aciphex long term."
+"preprocedure diagnosis:  complete heart block. postprocedure diagnosis:  complete heart block. procedures planned and performed1.  implantation of a dual-chamber pacemaker.2.  fluoroscopic guidance for implantation of a dual-chamber pacemaker. fluoroscopy time:  2.6 minutes. medications at the time of study1.  versed 2.5 mg.2.  fentanyl 150 mcg.3.  benadryl 50 mg. clinical history:  the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block.  she has been referred for a pacemaker implantation. risks and benefits:  risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient.  the patient agreed both verbally and via written consent. description of procedure:  the patient was transported to the cardiac catheterization laboratory in the fasting state.  the region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  lidocaine 1% (20 ml) was administered to the area.  after achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy.  a guide wire was advanced into the vein.  following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  hemostasis was achieved with electrocautery.  lidocaine 1% (10 ml) was then administered to the medial aspect of the incision.  a pocket was then fashioned in the medial direction.  using the previously placed wire, a 7-french side-arm sheath was advanced over the wire into the left axillary vein.  the dilator was then removed over the wire.  a second wire was then advanced into the sheath into the left axillary vein.  the sheath was then removed over the top of the two wires.  one wire was then pinned to the drape.  using the remaining wire, a 7 french side-arm sheath was advanced back into the left axillary vein.  the dilator and wire were removed.  a passive pacing lead was then advanced down into the right atrium.  the peel-away sheath was removed.  the lead was then passed across the tricuspid valve and positioned in the apical location.  adequate pacing and sensing functions were established.  suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  with the remaining wire, a 7-french side-arm sheath was advanced over the wire into the axillary vein.  the wire and dilating sheaths were removed.  an active pacing lead was then advanced down into the right atrium.  the peel-away sheath was removed.  preformed j stylet was then advanced into the lead.  the lead was positioned in the appendage location.  lead body was then turned, and the active fix screw was fixed to the tissue.  adequate pacing and sensing function were established.  suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  the pocket was then washed with antibiotic-impregnated saline.  pulse generator was obtained and connected securely to the leads.  the leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch.  sponge and needle counts were correct at the end of the procedure.  no acute complications were noted. device data1.  pulse generator, manufacturer boston scientific, model # ssncrf403, serial #1234.2.  right atrial lead, manufacturer guidant, model #4469, serial #1234.3.  right ventricular lead, manufacturer guidant, model #4457, serial #1234. measured intraoperative data1.  right atrial lead impedance 534 ohms.  p waves measured at 1.2 millivolts.  pacing threshold 1.0 volt at 0.5 milliseconds.2.  right ventricular lead impedance 900 ohms.  r-waves measured 6.0 millivolts.  pacing threshold 1.0 volt at 0.5 milliseconds. device settings:  ddd 60 to 130. conclusions1.  successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.2.  no acute complications. plan1.  the patient will be taken back to her room for continued observation.  she can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.2.  chest x-ray to rule out pneumothorax and verified lead position.3.  completion of the course of antibiotics.4.  home dismissal instructions provided in written format.5.  device interrogation in the morning.6.  wound check in 7 to 10 days.7.  enrollment in device clinic."
+"admission psychiatric evaluation identifying information/referral data:  this is a 16-year-old caucasian adolescent female who is going into ninth grade and lives with her mother, the mother&#8217;s boyfriend, and a 12, 11, and 10-year-old sister.  she also has a stepsister that is 8 years old.  the patient was brought in by her mother after being picked up by anchorage police department (apd).  she was brought to our institution for an assessment.   reason for admission/chief complaint:  the patient ran away in the middle of the night on sunday, 07/19/04, and she has been on the run since then.  her friends report to the parents that she is suicidal and that she had a knife.  a friend took a knife away from her to keep her from cutting herself.   history of present illness:  this is a 16-year-old caucasian adolescent girl who was brought in by apd and her parents.  this is her first admission.  apd picked her up from a runaway and brought her at her mother&#8217;s request after some friends told the mother that she was suicidal.  the mother found journals in her room talking about suicide, and that she has been raped.  there were no details and the client denies that she was raped.  she is sexually active with one boyfriend, also 16 years old, that she met while going to school in ketchican in the last school year.  she has been with the mother only the last two months and the same ketchican boyfriend, michael, followed her to anchorage.  she reports symptoms of depression, no energy, initial and middle insomnia, eating more.  she is very irritable and has verbal altercations wither sister who is 14.  she admits to being sad and also having poor concentration.  she had marked drop in school functioning in the last year, and will need to repeat the ninth grade.  the mother is very concerned with the patent&#8217;s safety and feels she is not able to control her.  she lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in ketchican.  she went to live with her dad up to age 16.  now she is living with her mother and her mother&#8217;s boyfriend for the last two months.  in december, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed. legal history:  no legal history. treatment/psychiatric history:  the patient was evaluated once at xyz when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family.   family psychiatric history:  the patient has three siblings with adhd (attention deficit hyperactivity disorder) and two of her siblings are in an rtc (residential treatment center) program, one with the diagnosis of bipolar disorder, and the other with adhd and bipolar condition. pertinent medical history:  she was born with some eczema.  at age 4 she was involved in an accident where she cut one of her legs and needed sutures.  there is no history of seizure or head injury.  she reports loss of consciousness.  this will be investigated; there are no details about it.  she admits to being sexually active, protecting herself using condoms.  her last menstruation period was 07/20/04.   allergies:  no allergies. development age factors:  the mother reports she was born with some jaundice and eczema.  early milestones walk and talk.  the patient appears to function at the expected age level.   pertinent psychosocial data:  complete pertinent psychosocial will be obtained by our clinician.  the patient admits witnessing seeing some domestic violence when she was small, around five years old.  there is an allegation of a rape that the mother found in her journal, but this is going to be investigated.   school history:   mostly ds and fs since last two years and she will need to repeat the ninth grade and home school.    substance abuse history:  the patient denied the use of any substance. assets:1.   the patient is cooperative. 2.   she is healthy.3.   the family is motivated for treatment.  liabilities:1.   running away.2.   exposure to traumatic incidents.3.   poor insight and judgment.4.   high-risk behaviors.   admission mental status examination:  this patient is alert, oriented x4, and cooperative.  disheveled at the time of admission.  no visible movement disorder observed.  poor visual contact.  her speech is normal.  her mood seems anxious and sad.  her affect is restricted.  she denied any suicidal or homicidal ideation.  she denied perceptual disorder.  she reports being scared of being here, &quot;i don&#8217;t need to be in a place like this&quot;.  poor concentration.  poor insight.  when asked about her problems or her needs, she reports &#8216;i don&#8217;t need help&quot;.  very poor judgment.  the patient tends to minimize her high-risk behavior.   her three wishes include:1.    being at home.2.    to see my boyfriend.3.    not to have any problems.  as a grownup, she would just like to finish her high school, and go live with her boyfriend and get an apartment.   discussion:  this is a 16-year-old adolescent girl who reports during the last eight months, since december when her grandmother passed away, she has been feeling depressed and sad.  some social dysfunction, failing at school, also having a lot of family conflicts.  she ran away from her house, a suicidal gesture was reported by her friends, which she denies, but some journals at her house about dark subjects and suicidal ideations were found by her mother.  the patient is with some depressive symptoms.  the mother is afraid of not being able to control her.  the patient will be admitted for stabilization of her symptoms and for her safety.  the client denied suicidal ideation.  the parents feel that the patient is not safe.    initial treatment plan:  the patient will be returning to previous living arrangement and going home.  the patient will be admitted to the adolescent girl unit.  a complete psychosocial evaluation will be done by our therapist.  a complete medical evaluation will be done by our medical consultant.  the psychiatrist will see the patient on a daily basis and recommend medication if the patient needs it and collaborate with the treatment team.  this patient will be placed on level ii, full awol.  consent for benadryl was obtained to help her in her sleeping problem.  suicidal awol precautions were ordered.   initial discharge planning:  once the patient is stable, she will be returning home with outpatient treatment recommendation."
+"admission diagnosis:1. respiratory arrest.2 . end-stage chronic obstructive pulmonary disease.3. coronary artery disease.4. history of hypertension. discharge diagnosis:1. status post-respiratory arrest.2. chronic obstructive pulmonary disease.3. congestive heart failure.4. history of coronary artery disease.5. history of hypertension. summary:  the patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. the patient"
+"cc: left sided weakness. hx: 74 y/o rhf awoke from a nap at 11:00 am on 11/22/92 and felt weak on her left side. she required support on that side to ambulate. in addition, she felt spoke as though she &quot;was drunk.&quot; nevertheless, she was able to comprehend what was being spoken around her. her difficulty with speech completely resolved by 12:00 noon. she was brought to uihc etc at 8:30am on 11/23/92 for evaluation. meds: none.  allergies:  asa/ pcn both cause rash. pmh: 1)?htn. 2)copd. 3)h/o hepatitis (unknown type). 4)macular degeneration. shx: widowed; lives alone. denied etoh/tobacco/illicit drug use. fhx: unremarkable. exam:  bp191/89 hr68 rr16 37.2c ms: a &#038; o to person, place and time. speech fluent; without dysarthria. intact naming, comprehension, and repetition. cn: central scotoma, os (old). mild upper lid ptosis, od (old per picture). lower left facial weakness. motor: mild left hemiparesis (4+ to 5- strength throughout affected side). no mention of muscle tone in chart. sensory: unremarkable. coord: impaired fnf and hks movement secondary to weakness. station: left pronator drift. no romberg sign seen. gait: left hemiparetic gait with decreased lue swing. reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. plantars: left babinski sign; and flexor on right. general exam: 2/6 sem at left sternal border. course: gs, cbc, pt, ptt, ck, esr were within normal limits. abc 7.4/46/63 on room air. ekg showed a sinus rhythm with right bundle branch block. mri brain, 11/23/95, revealed a right pontine pyramidal tract infarction. she was treated with ticlopidine 250mg bid. on 11/26/92, her left hemiparesis worsened. a hct, 11/27/92, was unremarkable. the patient was treated with iv heparin. this was discontinued the following day when her strength returned to that noted on 11/23/95. on 11/27/92, she developed angina and was ruled out for mi by serial ekg and cardiac enzyme studies. carotid duplex showed 0-15% bilateral ica stenosis and antegrade vertebral artery flow bilaterally. transthoracic echocardiogram revealed aortic insufficiency only. transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. there was calcification and possible thrombus seen in the descending aorta. cardiology did not feel the later was an indication for anticoagulation. she was discharged home on isordil 20 tid, metoprolol 25mg q12hours, and ticlid 250mg bid."
+"referral indication1.  tachybrady syndrome.2.  chronic atrial fibrillation. procedures planned and performed1.  implantation of a single-chamber pacemaker.2.  fluoroscopic guidance for implantation of single-chamber pacemaker. fluoroscopy time:  1.2 minutes. medications at the time of study1.  ancef 1 g.2.  benadryl 50 mg.3.  versed 3 mg.4.  fentanyl 150 mcg. clinical history:  the patient is a pleasant 73-year-old female with chronic atrial fibrillation.  she has been found to have tachybrady syndrome, has been referred for pacemaker implantation. risks and benefits:  risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  the patient agreed both verbally and via written consent.  risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  the patient agreed both verbally and via written consent. description of procedure:  the patient was transported to the cardiac catheterization laboratory in a fasting state.  the region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  lidocaine 1% (20 ml) was administered to the area.  percutaneous access of the left axillary vein was then performed.  a wire was then advanced in the left axillary vein using fluoroscopy.  following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  lidocaine 1% (10 ml) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  using the previously placed guidewire, a 7-french sidearm sheath was advanced over the wire into the vein.  the dilator and wire were removed.  an active pacing lead was then advanced down in the right atrium.  the peel-away sheath was removed.  lead was passed across the tricuspid valve and positioned in an apical septal location.  this was an active fixed lead and the screw was deployed.  adequate pacing and sensing function were established.  the suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  the pocket was washed with antibiotic-impregnated saline.  a pulse generator was obtained and connected securely to the lead.  the lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch.  no acute complications were noted. device data1.  pulse generator, manufacturer st. jude model 5626, serial #123456.2.  right ventricular lead, manufacturer st. jude model 1688tc52, serial #abcd123456. measured intraoperative data:  right ventricular lead impedance 630 ohms.  r wave measures 17.5 mv.  pacing threshold of 0.8 v at 0.5 msec. device settings:  vvi 70 to 120. conclusions1.  successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.2.  no acute complications. plan1.  the patient will be admitted for overnight observation and dismissed at the discretion of primary service.2.  chest x-ray to rule out pneumothorax and verify lead position.3.  completion of course of antibiotics.4.  device interrogation in the morning.5.  home dismissal instructions provided in a written format.6.  wound check in 7 to 10 days.7.  enrollment in device clinic."
+"<strong>exam: </strong>ct abdomen and pelvis without contrast, stone protocol, reconstruction. <strong>reason for exam: </strong>flank pain. <strong>technique: </strong>noncontrast ct abdomen and pelvis with coronal reconstructions. <strong>findings: </strong>there is no intrarenal stone bilaterally. however, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. the right renal pelvis is not dilated. there is no stone along the course of the ureter. i cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. there is no obvious solid-appearing mass given the lack of contrast. scans of the pelvis disclose no evidence of stone within the decompressed bladder. no pelvic free fluid or adenopathy. there are few scattered diverticula. there is a moderate amount of stool throughout the colon. there are scattered diverticula, but no ct evidence of acute diverticulitis. the appendix is normal. there are mild bibasilar atelectatic changes. given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. the gallbladder is present. there is no abdominal free fluid or pathologic adenopathy. there are degenerative changes of the lumbar spine. <strong>impression:</strong> 1.very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. there is no stone identified along the course of the left ureter or in the bladder. could this patient be status post recent stone passage? clinical correlation is advised. 2.diverticulosis. 3.moderate amount of stool throughout the colon. 4.normal appendix."
+"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."
+"clinical history:  a 48-year-old smoker found to have a right upper lobe mass on chest x-ray and is being evaluated for chest pain.  pet scan demonstrated a mass in the right upper lobe and also a mass in the right lower lobe, which were also identified by ct scan.  the lower lobe mass was approximately 1 cm in diameter and the upper lobe mass was 4 cm to 5 cm in diameter.  the patient was referred for surgical treatment. specimen:a.  lung, wedge biopsy right lower lobeb.  lung, resection right upper lobec.  lymph node, biopsy level 2 and 4d.  lymph node, biopsy level 7 subcarinal final diagnosis:a.  wedge biopsy of right lower lobe showing:  adenocarcinoma, grade 2, measuring 1 cm in diameter with invasion of the overlying pleura and with free resection margin.b.  right upper lobe lung resection showing:  adenocarcinoma, grade 2, measuring 4 cm in diameter with invasion of the overlying pleura and with free bronchial margin.  two (2) hilar lymph nodes with no metastatic tumor.c.  lymph node biopsy at level 2 and 4 showing seven (7) lymph nodes with anthracosis and no metastatic tumor.d.  lymph node biopsy, level 7 subcarinal showing (5) lymph nodes with anthracosis and no metastatic tumor. comment:  the morphology of the tumor seen in both lobes is similar and we feel that the smaller tumor involving the right lower lobe is most likely secondary to transbronchial spread from the main tumor involving the right upper lobe.  this suggestion is supported by the fact that no obvious vascular or lymphatic invasion is demonstrated and adjacent to the smaller tumor, there is isolated nests of tumor cells within the air spaces.  furthermore, immunoperoxidase stain for ck-7, ck-20 and ttf are performed on both the right lower and right upper lobe nodule.  the immunohistochemical results confirm the lung origin of both tumors and we feel that the tumor involving the right lower lobe is due to transbronchial spread from the larger tumor nodule involving the right upper lobe."
+"admission diagnoses:1.  syncope.2.  end-stage renal disease requiring hemodialysis.3.  congestive heart failure.4.  hypertension. discharge diagnoses:1.  syncope.2.  end-stage renal disease requiring hemodialysis.3.  congestive heart failure.4.  hypertension. condition on discharge:  stable. procedure performed:  none. hospital course:  the patient is a 44-year-old african-american male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago.  he reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes.  he reportedly had this even while seated and denied overt dizziness.  he reports this lightheadedness is made even worse when standing.  he has had these symptoms almost daily over the past month.  he does report some confusion when he awakens.  he reports that he loses consciousness for two to three minutes.  denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease.  he denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope.  there were no witnesses to his syncopal episodes.  he also denied any clonic activity and no history of seizures.  in the emergency room, the patient was given fluids and orthostatics were checked.  at that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension.  the patient presented to the hospital on coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease.  regarding his syncopal episodes, he was admitted with likely orthostatic hypotension.  cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily.  at that time, the coreg had been held secondary to hypotension.  cardiology also ordered a nuclear medicine myocardial perfusion stress test.  regarding the end-stage renal disease, nephrology was consulted as the patient was due for hemodialysis treatment the day following admission.  nephrology was able to perform dialysis on the patient and renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame.  renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the coreg to 6.25 mg b.i.d.  they reported that the procrit should be continued.  as previously indicated regarding the dilated cardiomyopathy, cardiology ordered a nuclear medicine stress test to be performed.  also, regarding the patient&#8217;s hypertension, he actually was noted to have hypotension on admission, and as previously stated, the coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well.  the patient&#8217;s hospital course remained uncomplicated until september 17, 2007, the day the nuclear medicine stress test was scheduled.  the patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice. discharge instructions/medications:the patient left ama.  no specific discharge instructions and medications were given.  at the time of the patient leaving ama, his medications were as follows:1.  aspirin 81 mg p.o. daily.2.  multivitamin, nephrocaps one cap p.o. daily.3.  fosrenol 500 mg chewable t.i.d.4.  lisinopril 2.5 mg daily.6.  coreg 3.125 mg p.o. b.i.d.7.  procrit 10,000 units inject every tuesday, thursday, and saturday.8.  heparin 5000 units q.8h. subcutaneous for dvt prophylaxis."
+"problem:  prescription evaluation for crohn&#8217;s disease. history:  this is a 46-year-old male who is here for a refill of imuran.  he is taking it at a dose of 100 mg per day.  he is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  in fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. an x-ray was performed, which showed no signs of obstruction per his report.  he thinks that the inciting factor of this incident was too many grapes eaten the day before.  he has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  the patient&#8217;s normal bowel pattern is loose stools and this is unchanged recently.  he has not had any rectal bleeding. he asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with iv insertion.  he has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  the tenderness has now completely resolved.   he had a colonoscopy performed in august of 2003, by dr. s.  an anastomotic stricture was found at the terminal ileum/cecum junction.  dr. s recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  no active crohn&#8217;s disease was found during the colonoscopy.   earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  at that time he was taking a lot of tylenol for migraine-type headaches.  under dr. s&#8217;s recommendation, he stopped the imuran for one month and reduced his dose of tylenol.  since that time his liver enzymes have normalized and he has restarted the imuran with no problems.   he also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  it used to occur once a week only, but has now increased in frequency to twice a week.  he takes over-the-counter h2 blockers as needed, as well as tums.  he associates the onset of his symptoms with eating spicy mexican food. past medical history:  reviewed and unchanged. allergies:  no known allergies to medications. operations:  unchanged. illnesses:  crohn&#8217;s disease, vitamin b12 deficiency. medications:  imuran, nascobal, vicodin p.r.n. review of systems:  dated 08/04/04 is reviewed and noted.  please see pertinent gi issues as discussed above.  otherwise unremarkable. physical examination:   general:  pleasant male in no acute distress.  well nourished and well developed. skin: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  non-tender to palpation. no erythema or red streaking.  no edema. lymph:  no epitrochlear or axillary lymph node enlargement or tenderness on the right side.  data reviewed: labs from june 8th and july 19th reviewed.  liver function tests normal with ast 14 and alt 44.  wbcs were slightly low at 4.8.  hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  these results were reviewed by dr. s and lab results letter sent. impression:  1. crohn&#8217;s disease, status post terminal ileum resection, on imuran.  intermittent symptoms of bowel obstruction.  last episode three weeks ago.2.  history of non-specific hepatitis while taking high doses of tylenol.  now resolved. 2.  increased frequency of reflux symptoms.3.  superficial thrombophlebitis, resolving. 4.  slightly low h&#038;h. plan:  1.  we discussed dr. s&#8217;s recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  the patient emphatically states that he does not want to consider dilation at this time.  the patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  he states understanding of this. advised to maintain low residue diet to avoid obstructions. 2.  continue with liver panel and abc every month per dr. s&#8217;s instructions.3.  continue imuran 100 mg per day.4.  continue to minimize tylenol use.  the patient is wondering if he can take another type of medication for migraines that is not tylenol or antiinflammatories or aspirin.  dr. s is consulted and agrees that imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. the patient will make an appointment with his primary care provider to discuss this further. 5.  reviewed the importance of prophylactic treatment of reflux-type symptoms.  encouraged the patient to take over-the-counter h2 blockers on a daily basis to prevent symptoms from occurring.  the patient will try this and if he remains symptomatic, then he will call our office and a prescription for zantac 150 mg per day will be provided.  reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  he does not want to undergo any type of procedure such as that at this time.6.    his thrombophlebitis appears to be resolving and does not have any alarming features present.  no treatment is needed at this time. he is instructed to call our office or his pcp if he experiences any pain, red streaking or fever. 7.  we will watch his cbc carefully to ensure that the h&#038;h does not continue to drop.  if it does, then he may need further evaluation with iron studies, b12 levels, or a gi evaluation.   followup:  continue liver panel and abc every month; follow up pending these results.  call our office for obstructive symptoms or continued reflux.  otherwise prescription evaluation in one year."
+"cc: dysarthria hx: this 52y/o rhf was transferred from a local hospital to uihc on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. she was a belted passenger in a car struck at a stop. there was no reported head or neck injury or alteration of consciousness. she was treated and released from a local er the same day. her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. in 4/94 she developed stress urinary incontinence which spontaneously resolved in june. in 8/94, her ha changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. she also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. in 9/94 she was evaluated by a local physician. examination then revealed incoordination, generalized fatigue, and dysarthria. soon after this she became poorly arousable and increasingly somnolent. she had difficulty walking and generalized weakness. on 10/14/94, she lost the ability to walk by herself. evaluation at a local hospital revealed: 1)normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of &quot;tumor or reactive lymphocytosis.&quot; one of these csf analysis showed: glucose 16, protein 99, wbc 14, rbc 114. echocardiogram was normal. bone marrow biopsy was normal except for decreased iron. abdominal-pelvic ct scan, cxr, mammogram, ppd, ana, tft, and rpr were unremarkable. a 10/31/94 mri brain scan a 5x10mm area of increased signal on t2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. these areas did not enhance with gadolinium contrast on t1 weighted images. meds: none. pmh: 1)g3p3, 2)last menses one year ago. fhx: mother suffered stroke in her 70&#8242;s. dm and htn in family. shx: married, secretary, no h/o tobacco/etoh/illicit drug use. ros: no weight loss, fever, chills, nightsweats, cough, dysphagia. exam: bp139/74, hr 90, rr20, 36.8c ms: drowsy to somnolent, occasionally &quot;giddy.&quot; oriented to person, place, time. minimal dysarthric speech, but appropriate. mmse 27/30 (copy of exam not in chart). cn: pupils 4/4 decreasing to 2/2 on exposure to light. optic disks were flat and without sign of papilledema. vfftc. eom intact. no nystagmus. the rest of the cn exam was unremarkable. motor: 5/5 strength throughout. normal muscle tone and bulk. sensory: no deficit to lt/pp/vib/prop. coord: difficulty with ram in bue, and ataxia on fnf and hks in all extremities. station: romberg sign present. gait: unsteady, wide-based, with notable difficulty on tw, tt and hw. reflexes: 2/2 bue, 0/1 patellae, trace at both archilles, plantars responses were flexor, bilaterally. gen exam: unremarkable. course: csf analysis by lumbar puncture, 10/31/94: protein 131mg/dl (normal 15-45), albumin 68 (normal 14-20), igg10mg/dl (normal &lt;6.2), igg index -o.1mg/24hr (normal), no oligoclonal bands seen, wbc 33 (19lymphocytes, 1 neutrophil), rbc 29, glucose 13, cultures (bacteria, fungal, afb) were negative, crytococcal ag negative. the elevated csf total protein, igg, and albumin suggested breakdown of the blood brain barrier or blockage of csf flow. the normal igg synthesis rate and lack of oligoclonal banding did not suggest demylination. a second csf analysis on 11/2/94 revealed similar findings; and in addition anti-purkinje cell and anti-neuronal antibodies (yo and ho) were not found; beta-2 microglobulin was 1.8 (normal); histoplasmosis ag negative. serum ace, spep, urine histoplasmin were negative. neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the mmpi (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. severe defects in memory, fine motor skills, and constructional praxis were noted. chest-abdominal-pelvic ct scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the rmca, laca and left aica distributions. it was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of iv steroids. temporal artery biopsy was unremarkable. she underwent multiple mri brain scans at uihc: 11/4/94, 11/9/94, 11/16/94. all scans consistently showed increase in t2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. these areas did not enhance with gadolinium contrast. these findings were felt most suggestive of glioma. she underwent left temporal lobe brain biopsy on 11/10/94: this study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. little sign of vasculopathy or tumor was found. bacterial, fungal , hsv, cmv and afb cultures were negative. hsv, and vzv antigen was negative. her neurological state progressively worsened throughout her hospital stay. by time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required ngt feeding and 24hour supportive care. she was made dnr after family request prior to transfer to a care facility."
+"preoperative diagnosis:  persistent pneumonia, right upper lobe of the lung, possible mass. postoperative diagnosis:  persistent pneumonia, right upper lobe of the lung, possible mass. procedure:  bronchoscopy with brush biopsies. description of procedure:  after obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  a time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  first the trachea and the carina had normal appearance.  the scope was passed into the left side and the bronchial system was found to be normal.  there were scars and mucoid secretions.  then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and tb.  first, the basal lobes were explored and found to be normal.  then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  brush biopsy was obtained from one of the segments and sent to pathology. the procedure had to be interrupted several times because of the patient&#8217;s desaturation, but after a few minutes of ambu bagging, he recovered satisfactorily. at the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition."
+"reason for consult:  depression. hpi:  the patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before thanksgiving in 2006.  the patient was diagnosed and treated for a t9 compression fraction with vertebroplasty.  soon after discharge, the patient was readmitted with severe mid low back pain and found to have a t8 compression fracture.  this was also treated with vertebroplasty.  the patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  her pain is in her upper back around her shoulder blades.  the patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  mri on january 29, 2007, was positive for possible meningioma to the left of anterior box. the patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  does not see any future for herself.  reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  admits to decreased appetite, feeling depressed, and always wanting to be alone.  claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at terrace.  denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  denies auditory and visual hallucinations.  no paranoid, delusions, or other abnormalities of thought content.  denies panic attacks, flashbacks, and other feelings of anxiety.  does admit to feeling restless at times.  is concerned with her physical appearance while in the hospital, i.e., her hair looking &quot;awful.&quot; past medical history:  hypertension, cataracts, hysterectomy, mi, osteoporosis, right total knee replacement in april 2004, hip fracture, and newly diagnosed diabetes.  no history of thyroid problems, seizures, strokes, or head injuries. current medications:  norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, lipitor 20 mg p.o. daily, klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, lexapro 10 mg p.o. daily, tricor 145 mg p.o. each bedtime, lasix 20 mg p.o. daily, ismo 20 mg p.o. daily, lidocaine patch, zestril, prinivil 40 mg p.o. daily, lopressor 75 mg p.o. b.i.d., starlix 120 mg p.o. t.i.d., pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 meq p.o. t.i.d., norco one tablet p.o. q.4h. p.r.n., zofran 4 mg iv q.6h. home medications:  unknown. allergies:  codeine (hallucinations). family medical history:  unremarkable. past psychiatric history:  unremarkable.  never taken any psychiatric medications or have ever had a family member with psychiatric illness. social/developmental history:  unremarkable childhood.  married for 40 plus years, widowed in 1981.  worked as administrative assistant in utmb hospitals vp&#8217;s office.  two children.  before admission, lived in the terrace independent living center.  was happy and very active while living there.  had friends in the terrace and would not mind going back there after discharge.  occasional glass of wine at dinner.  denies ever using illicit drugs and tobacco. mental status exam:  the patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  slight decrease in motor activity.  normal eye contact.  speech, low volume and rate.  good articulation and inflexion.  normal concentration.  mood, labile, tearful at times, depressed, then euthymic.  affect, mood congruent, full range.  thought process, logical and goal directed.  thought content, no delusions, suicidal or homicidal ideations.  perception, no auditory or visual hallucinations.  sensorium, alert, and oriented x3.  memory, fair.  information and intelligence, average.  judgment and insight, fair. mini mental status exam:  a 28/30.  could not remember two out of the three recalled words. assessment:  the patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  the patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital. axis i:  major depression disorder.axis ii:  deferred.axis iii:  osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, mi, and right total knee replacement.axis iv:  lives independently at terrace, difficulty walking, hospitalization.axis v:  45. plan:  continue lexapro 10 mg daily and pamelor 25 mg each bedtime monitor for adverse effects of tca and worsening of depressive symptoms.  discussed about possible inpatient psychiatric care. thank you for the consultation."
+"cc: headache (ha) hx: 10 y/o rhm awoke with a bilateral parieto-occipital ha associated with single episode of nausea and vomiting, 2 weeks prior to presentation. the nausea and vomiting resolved and did not recur. however, he continued to experience similar ha 3-4 times per week during the early morning upon awakening. he never felt the ha awakened him from sleep. the ha were partially relieved by tylenol or advil, and he distracted himself from the pain by remaining active. one week prior to presentation, he started to experience short episodes of blurred vision and diplopia. he also became fatigued, less active, and frequently yawned. he had no prior history of ha and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness. the patient underwent an mri brain scan prior to transfer to uihc. this revealed a mass in the left frontal region adjacent to the left temporal horn. the mass was an inhomogeneous blend of signals on t1 and t2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass. meds: none. pmh: 1) he was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. his post-partum course was unremarkable. 2)developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) no significant illnesses or hospitalizations. fhx: mgf (meningioma). pgf (lymphoma). mother (migraine ha). father and 22yr old brother are alive and well. shx: lives with parents and attends mainstream 5th grade classes. exam: bp124/93 hr96 rr20 37.9c (tympanic) ms:  a &#038; o to person, place, time. cooperative and interactive. speech fluent and without dysarthria. cn: eom intact. vfftc, pupils 3/3 decreasing to 2/2 on exposure to light. fundoscopy: optic disks flat, no evidence of hemorrhage. the rest of the cn exam was unremarkable. motor: full strength throughout all 4 extremities. normal muscle tone and bulk. sensory: unremarkable. coord: unremarkable. station: no pronator drift or romberg sign gait: unremarkable. reflexes: 2+ in rue and rle. 3 in lue and lle. plantar responses were flexor, bilaterally. heent: no meningismus. no cranial bruits. no skull defects palpated. gen exam: unremarkable. course: gs, pt/ptt, cbc were unremarkable. the mri finding above lead to a differential diagnosis of venous angioma, arteriovenous malformation, ependymoma, neurocytoma, glioma: all with associated hemorrhage. he underwent cerebral angiography on 1/25/93. upon injection of the rcca an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. the internal cerebral vein is displaced to the left suggesting mass effect. there is a hypoplastic a1 segment and fetal origin of the lpca. the mass was felt by neuroradiology to represent a hematoma. he underwent a right frontal craniotomy, 1/28/93. pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. there were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. this was consistent with venous angioma/malformation."
+"procedure in detail:  following premedication with vistaril 50 mg and atropine 0.4 mg im, the patient received versed 5.0 mg intravenously after cetacaine spray to the posterior palate.  the olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  the upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  no evidence of friability, ulceration or tumor mass was encountered.  the instrument was withdrawn to the antrum, and biopsies taken for clo testing, and then the instrument removed."
+"the patient was placed in the left lateral decubitus position, and the above medications were administered.  the oropharynx was sprayed with cetacaine.  the endoscope was passed under direct visualization into the esophagus.  the entire esophageal mucosa was normal.  the entire gastric mucosa was normal, including a retroflexed view of the fundus.  the entire duodenal mucosa was normal to the second portion.  the patient tolerated the procedure without complication."
+"cc: progressive left visual field loss. hx: this 46y/o rhf with polymyositis since 1988, presented with complaint of visual field loss since 12/94. the visual field loss was of gradual onset and within a month of onset became a left homonymous hemianopsia. she began experiencing stiffness, numbness, tingling and incoordination of her left hand, 6 weeks prior to this admission,. these symptoms were initially attributed to carpal tunnel syndrome. mri scan of the brain (done locally) on 6/23/95 revealed increased periventricular white matter signal on t2 images, particularly in the left temporo-occipital and right parietal lobes. there was ring enhancement of a lesion in the left occipital lobe on t1 gadolinium contrast enhanced images. there was gyral enhancement near the right sylvian fissure. cerebral angiogram on 7/19/95 (done locally) was unremarkable. lumbar puncture on 7/19/95 was unremarkable. she complained of frequent holocranial throbbing headaches for the past 6 months; the ha&#8217;s are associated with photophobia, phonophobia and nausea, but no vomiting. she has also been experiencing chills and night sweats for the past 2-3 weeks. she denies weight loss, but acknowledged decreased appetite and increased generalized fatigue for the past 3-4 months. she was diagnosed with polymyositis in 1988 with slowly progressive bilateral lower extremity weakness. she has been on immunosuppressive drugs since 1988, including prednisone, prednisone and methotrexate, cyclosporin, imuran, cytoxan, and plaquenil. at present she in ambulatory with use of walker. her last ck=3,125 and esr=16, on 6/28/95. meds: prednisone 20mg qd, cytoxan 75mg qd, zantac 150mg bid, vasotec 10mg bid, premarin 0.625 qd, provera 2.5mg qd, caco3 500mg bid, vit d 50,000units qweek, vit e qd, mvi 1 tab qd. pmh: 1)polymyositis diagnosed in 1988 by muscle biopsy. 2)hypertension. 3)lichen planus. 4)lower extremity deep venous thrombosis one year ago&#8211;placed on coumadin and this resulted in postmenopausal bleeding. fhx: mother is alive and has a h/o htn and stroke. father died in motor vehicle accident at age 40 years. shx: married, 3 children who are healthy. she denied any tobacco/etoh/illicit drug use. exam: bp160/74 hr95 rr12 35.8c wt. 86.4kg ht. 5&#8217;6&quot; ms: a&#038;o to person, place and time. speech was normal. mood euthymic with appropriate affect. cn: pupils 4/4 decreasing to 2/2 on exposure to light. no rapd noted. optic disk were flat. eom testing unremarkable. confrontational visual field testing revealed a left homonymous hemianopsia. the rest of the cn exam was unremarkable. motor: upper extremities: 5/5 proximally, 5/4 @ elbow/wrist/hand. lower extremities: 4/4 proximally and 5/5 @ and below knees. sensory: unremarkable. coord: dyssynergia of lue fnf movement. slowed finger tapping on left. hns movements were normal, bilaterally. station: lue drift and fix on arm roll. no romberg sign elicited. gait: waddling gait, but could tt and stand on both heels. she had difficulty with tandem walking, but did not fall to any particular side. reflexes: 2/2 brachioradialis and biceps. 2/2+ triceps, 1+/1+ patellae, 1/1 achilles. plantar responses were flexor on the right and withdrawal response on the left. gen exam: no rashes. ii/vi systolic ejection murmur at the left sternal border. course: electrolytes, pt/ptt, urinalysis and cxr were normal. esr=38 (normal&lt;20), crp1.4 (normal&lt;0.4). ck 2,917, ldh 356, ast 67. mri brain, 8/8/95, revealed slight improvement of the abnormal white matter changes seen on previous outside mri. in addition new sphenoid sinus disease suggestive of sinusitis was seen. she underwent stereotactic biopsy of the right parietal region on 8/10/95 which on h&#038;e and lfb stained sections revealed multiple discrete areas of demyelination, containing dense infiltrates of foamy macrophages in association with scattered large oligodendroglia with deeply basophilic, ground-glass nuclei, enlarged astrocytes, and sparse perivascular lymphocytic infiltrates. in situ hybridization performed on block a2 (at the university of pittsburgh) is positive for jc virus. the ultrastructural studies demonstrated no viral particles. she was tapered off all immunosuppressive medications and her polymyositis remained clinically stable. she had a seizure in 12/95 and was placed on dilantin. her neurologic deficits worsened slightly, but reached a plateau by 10/96, as indicated by a 4/14/97 neurology clinic visit note. 1/22/96, mri brain demonstrated widespread hyperintense signal on t2 and proton density weighted images throughout the deep white matter in both hemispheres, worse on the right side. there was interval progression of previously noted abnormalities and extension into the right frontal and left parieto-occipital regions. there was progression of abnormal signal in the basal ganglia, worse on the right, and new involvement of the brainstem."
+"clinical history:  probable right upper lobe lung adenocarcinoma. specimen:  lung, right upper lobe resection. gross description:  specimen is received fresh for frozen section, labeled with the patient&#8217;s identification and &quot;right upper lobe lung&quot;.  it consists of one lobectomy specimen measuring 16.1 x 10.6 x4.5.cm.  the specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  this mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  there is no necrosis or hemorrhage evident.  the tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered. final diagnosis:  right lung, upper lobe, lobectomy:  bronchioloalveolar carcinoma, mucinous type comment:  right upper lobe, lobectomy.tumor type:  bronchioloalveolar carcinoma, mucinous type.histologic grade:  well differentiated.tumor size (greatest diameter):  3.6 cm.blood/lymphatic vessel invasion:  absent.perineural invasion:  absent.bronchial margin:  negative.vascular margin:  negative.inked surgical margin:  negative.visceral pleura:  not involved.in situ carcinoma:  absent.non-neoplastic lung:  emphysema.hilar lymph nodes:  number of positive lymph nodes:  0; total number of lymph nodes:  1.p53 immunohistochemical stain is negative in the tumor."
+"preoperative diagnosis:  right frontotemporal chronic subacute subdural hematoma. postoperative diagnosis:  right frontotemporal chronic subacute subdural hematoma. title of the operation:  right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques. assistant:  none. indications:  the patient is a 75-year-old man with a 6-week history of decline following a head injury.  he was rendered unconscious by the head injury.  he underwent an extensive syncopal workup in mississippi.  this workup was negative.  the patient does indeed have a heart pacemaker.  the patient was admitted to abcd three days ago and yesterday underwent a ct scan, which showed a large appearance of subdural hematoma.  there is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  i decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  the patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead. description of procedure:  the patient was brought to the operating room where general and endotracheal anesthesia was obtained.  the head was turned over to the left side and was supported on a cushion.  there was a roll beneath the right shoulder.  the right calvarium was shaved and prepared in the usual manner with betadine-soaked scrub followed by betadine paint.  markings were applied.  sterile drapes were applied.  a linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  sharp dissection was carried down into subcutaneous tissue and bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  weitlaner retractors were inserted.  a single bur hole was placed underneath the temporalis muscle.  i placed the craniotomy a bit low in order to have better cosmesis.  a cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  the bone was set aside.  the dura was clearly discolored and very tense.  the dura was opened in a cruciate fashion with a #15 blade.  there was immediate flow of a thin motor oil fluid under high pressure.  literally the fluid shot out several inches with the first nick in the membranous cavity.  the dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  the margins of the membrane were coagulated.  the microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  the wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  the dura was then closed in a watertight fashion using running locking 4-0 nurolon.  tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the lorenz plating system.  the wound was irrigated thoroughly once more and was closed in layers.  muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 vicryl.  finally, the skin was closed with running locking 3-0 nylon. estimated blood loss for the case was less than 30 ml.  sponge and needle counts were correct. findings:  chronic subdural hematoma with multiple septations and thickened subdural membrane. i might add that the arachnoid was not violated at all during this procedure.  also, it was noted that there was no subarachnoid blood but only subdural blood."
+"history:  the patient was in the intensive care unit setting; he was intubated and sedated.  the patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated.  he has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output.  his creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia.  nephrology input has been requested for management of acute renal failure and acidosis. past medical history:1.  pancreatitis.2.  poison ivy.  the patient has recently been on oral steroids.3.  hypertension. medications:  include ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment. inpatient medications:  include protonix iv, half-normal saline at 125 ml an hour, d5w with 3 ounces of bicarbonate at 150 ml an hour.  the patient was initially on dopamine, which has now been discontinued.  the patient remains on levophed and invanz 1 g iv q.24 h. physical examination:  vitals, emergency room presentation, the blood pressure was 82/45.  his blood pressure in the icu had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% fio2.  the patient has had minimal urine output since admission.  heent, the patient is intubated at the moment.  neck examination, no overt lymph node enlargement.  no jugular venous distention.  lungs examination is benign in terms of crackles.  the patient has some harsh breath sounds secondary to being intubated.  cvs, s1 and s2 are fairly regular at the moment.  there is no pericardial rub.  abdominal examination, obese, but benign.  extremity examination reveals no lower extremity edema.  cns, the patient is intubated and sedated. laboratory data:  blood work, sodium 152, potassium 2.7, bicarbonate 13, bun 36, and creatinine 4.2.  the patient&#8217;s bun and creatinine yesterday were 23 and 2.1 respectively.  h&#038;h of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning.  the patient&#8217;s liver function tests are all out of whack and his alkaline phosphatase is 226, alt is 539, ck 1103, inr 1.66, and ammonia level of 55.  latest abgs show a ph of 7.04, bicarbonate of 10.7, pco2 of 40.3, and po2 of 120.7. assessment:1.  acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% fio2.  he has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis.  the patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight.  given the fact that he would need dialytic support for his electrolyte derangements and for volume control, i would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.2.  hypotension, which is significant and is related to his sepsis.  now the patient has been maintained on levophed and high rate of intravenous fluid at the moment.3.  acidosis, which is again secondary to his renal failure.  the patient was administered intravenous bicarbonate as mentioned above.  dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.4.  pancreatitis, which has been managed by his gastroenterologist.5.  sepsis, the patient is on broad-spectrum antibiotic therapy.6.  hypercalcemia.  the patient has been given calcium chloride.  we will need to watch for rebound hypercalcemia.7.  hypoalbuminemia.8.  hypokalemia, which has been repleted. recommendations:  again include continuation of iv fluid and bicarbonate infusion as well as transfer to the piedmont hospital for continuous venovenous hemodiafiltration."
+"chart note:  she is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  dr. xyz had seen her because of her complaints of shortness of breath.  then she had the pulmonary function test and ct scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see dr. xyz estep.  he had concurred with dr. xyz that an open lung biopsy was appropriate and she was actually scheduled for this but both dr. xyz and i were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  she was ready to go ahead with this and felt that it was important she find out why she is short of breath.  she is very concerned about the findings on her cat scan and pulmonary function test.  she seemed alarmed to report that dr. xyz had found that her lung capacity was reduced to 60% of what should be normal.  however, i told her that two years ago dr. xyz did pulmonary function studies which showed the same change in function.  and that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  after discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  in fact when i called dr. xyz to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  i also explained to patient that i did not think dr. xyz was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  and also i spoke with dr. xyz who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities. i had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  i also told her we could continue to monitor her breathing problems and continue to monitor her cat scan, x-ray, and pulmonary function tests.  and if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  but she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  she understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful. we are going to see her back in a month to see how her breathing is doing.  we will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  i told her i would try to talk to her sister sometime in the next day or two."
+"date of examination:  start:  12/29/2008 at 1859 hours.  end:  12/30/2008 at 0728 hours. total recording time:  12 hours, 29 minutes. patient history:  this is a 46-year-old female with a history of events concerning for seizures.  the patient has a history of epilepsy and has also had non-epileptic events in the past.  video eeg monitoring is performed to assess whether it is epileptic seizures or non-epileptic events. video eeg diagnoses1.  awake:  normal.2.  sleep:  activation of a single left temporal spike seen maximally at t3.3.  clinical events:  none. description:  approximately 12 hours of continuous 21-channel digital video eeg monitoring was performed.  during the waking state, there is a 9-hz dominant posterior rhythm.  the background of the record consists primarily of alpha frequency activity.  at times, during the waking portion of the record, there appears to be excessive faster frequency activity.  no activation procedures were performed. approximately four hours of intermittent sleep was obtained.  a single left temporal, t3, spike is seen in sleep.  vertex waves and sleep spindles were present and symmetric. the patient had no clinical events during the recording. clinical interpretation:  this is abnormal video eeg monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  the patient had no clinical events during the recording period.  clinical correlation is required."
+"discharge summary summary of treatment planning:two major problems were identified at the admission of this adolescent:1.   mood swings.2.   oppositional and defiant behavior.   a developmentally appropriate group oriented therapy program was the primary treatment modality for this adolescent.  he participated in at least eight psychoeducational and activity groups.  the attending psychiatrist provided evaluation for and management of psychotropic medications and collaborated with the treatment team.  the clinical therapist facilitated individual, group, and family therapy at least twice per week.   course in hospital:  during his hospitalization, the patient was seen initially as very depressed, withdrawn, some impulsive behavior observed, also oppositional behavior was displayed on the unit.  the patient also talked with a therapist about his family conflicts.  he was initiated on an antidepressant medication, zoloft, and he continued with adderall.  he responded well to zoloft, was less depressed.  he continued with behavior problems and mood swings.  a mood stabilizer was added to his treatment and with a positive response to it.  diagnostic and therapeutic test/evaluations:  sleep-deprived eeg was done, which was reported as normal.  his last depakote level was 57 as per 06/04/04. his laboratory basic metabolic panel, cbc, tsh were reported within normal limits.   consultations:  he was seen by our medical consultant for a complete history and medical examination.  no major acute problems were reported, only the acne.  treatment was initiated with face wash medication. final diagnosis:axis    i:        adhd (attention deficit hyperactivity disorder), rule out bipolar disorder and odd (oppositional defiant disorder).axis   ii:  deferred.axis  iii:        acne.axis  iv:        psychosocial stressors: severe, family conflicts and educational problems. axis   v:         gaf: 45 to 50.          conditions on discharge:  the patient had appropriate mood and was not engaging in self-injurious behavior.  he denied suicidal or homicidal ideation.  height: 5 foot 8 inches.  weight: 134.  blood pressure: 120/54.  pulse: 104.  respirations: 18.  temperature: 99. prognosis:   guarded. discharge plan:    as recommended by the treatment team, the patient was discharged to an rtc (residential treatment center) program to north star rtc.  he was transferred by personal staff of that institution.   discharge instructions/medications:  the patient is to continue treatment at north star rtc.  discharge medications are adderall xr 30 mg p.o. a.m., depakote 250 mg p.o. t.i.d., zoloft 55 mg p.o. q. a.m.  the prescription was given to the patient&#8217;s representative.  as other instructions, the patient may continue treatment at north star rtc with at least once a week family session.  the patient&#8217;s representative and the patient both acknowledged that they understand all the medications prescribed and how to administer them, and the importance of the next level of care and continuing treatment.  if he experiences any side effects or has any concerns regarding his behavior, safety, immediately contact north star hospital."
+"diagnosis:  possible cerebrovascular accident. description:  the eeg was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  the background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  a large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  hyperventilation was not performed.  no epileptiform activity or any definite lateralizing findings were seen. impression:  mildly abnormal study.  the findings are suggestive of a generalized cerebral disorder.  due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  clinical correlation is recommended."
+"preoperative diagnosis:  diarrhea, suspected irritable bowel. postoperative diagnosis:  normal colonoscopy.  premedications:  versed 5 mg, demerol 75 mg iv. reported procedure:  the rectal exam revealed no external lesions.  the prostate was normal in size and consistency. the colonoscope was inserted into the cecum with ease.  the cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  the scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated. endoscopic impression:  normal colonoscopy &#8211; no evidence of inflammatory disease, polyp, or other neoplasm.  these findings are certainly consistent with irritable bowel syndrome."
+"<strong>ct abdomen with and without contrast and ct pelvis with contrast</strong> <strong>reason for exam: </strong>generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08. <strong>technique:</strong> axial ct images of the abdomen were obtained without contrast. axial ct images of the abdomen and pelvis were then obtained utilizing 100 ml of isovue-300. <strong>findings: </strong>the liver is normal in size and attenuation. the gallbladder is normal. the spleen is normal in size and attenuation. the adrenal glands and pancreas are unremarkable. the kidneys are normal in size and attenuation. no hydronephrosis is detected. free fluid is seen within the right upper quadrant within the lower pelvis. a markedly thickened loop of distal small bowel is seen. this segment measures at least 10-cm long. no definite pneumatosis is appreciated. no free air is apparent at this time. inflammatory changes around this loop of bowel. mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident. no complete obstruction is suspected, as there is contrast material within the colon. postsurgical changes compatible with the partial colectomy are noted. postsurgical changes of the anterior abdominal wall are seen. mild thickening of the urinary bladder wall is seen. <strong>impression:</strong> 1. marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis. an inflammatory process such as infection or ischemia must be considered. close interval followup is necessary. 2. thickening of the urinary bladder wall is nonspecific and may be due to under distention. however, evaluation for cystitis is advised."
+"preoperative diagnosis:  post infarct angina. type of procedure:  left cardiac catheterization with selective right and left coronary angiography. procedure:  after informed consent was obtained, the patient was brought to the cardiac catheterization laboratory, and the groin was prepped in the usual fashion.  using 1% lidocaine, the right groin was infiltrated, and using the seldinger technique, the right femoral artery was cannulated.  through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 french pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  pressure measurements were obtained and cineangiograms in the rao and lao positions were then obtained.  catheter was then withdrawn and a #6 french non-bleed-back sidearm sheath was then introduced, and through this, a 6 french judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  cineangiograms were obtained of the left coronary system.  this catheter was then exchanged for a judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  cineangiograms were obtained, and the catheter and sheath were then withdrawn.  the patient tolerated the procedure well and left the cardiac catheterization laboratory in stable condition.  no evidence of hematoma formation or active bleeding.   complications:  none.   total contrast:  110 cc of hexabrix.   total fluoroscopy time:  1.8 minutes.   medications:  reglan 10 mg p.o., 5 mg p.o.  valium, benadryl 50 mg p.o. and heparin 3,000 units iv push."
+"operation1.  ivor-lewis esophagogastrectomy.2.  feeding jejunostomy.3.  placement of two right-sided #28-french chest tubes.4.  right thoracotomy. anesthesia:  general endotracheal anesthesia with a dual-lumen tube. operative procedure 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.  prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  in addition, he had a dual-lumen endotracheal tube placed.  the patient was placed in the supine position to begin the procedure.  his abdomen and chest were prepped and draped in the standard surgical fashion.  after applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  dissection was carried down through the linea using bovie electrocautery.  the abdomen was opened.  next, a balfour retractor was positioned as well as a mechanical retractor.  next, our attention was turned to freeing up the stomach.  in an attempt to do so, we identified the right gastroepiploic artery and arcade.  we incised the omentum and retracted it off the stomach and gastroepiploic arcade.  the omentum was divided using suture ligature with 2-0 silk.  we did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  next, we turned our attention to performing a kocher maneuver.  this was done and the stomach was freed up.  we took down the falciform ligament as well as the caudate attachment to the diaphragm.  we enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  we also did a portion of the esophageal dissection from the abdomen into the chest area.  the esophagus and the esophageal hiatus were identified in the abdomen.  we next turned our attention to the left gastric artery.  the left gastric artery was identified at the base of the stomach.  we first took the left gastric vein by ligating and dividing it using 0 silk ties.  the left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  at this point the stomach was freely mobile.  we then turned our attention to performing our jejunostomy feeding tube.  a 2-0 vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of treitz.  we then used bovie electrocautery to open the jejunum at this site.  we placed a 16-french red rubber catheter through this site.  we tied down in place.  we then used 3-0 silk sutures to perform a witzel.  next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  after doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  this was done with #1 prolene.  we put in a 2nd layer of 2-0 vicryl.  the skin was closed with 4-0 monocryl. next, we turned our attention to performing the thoracic portion of the procedure.  the patient was placed in the left lateral decubitus position.  the right chest was prepped and draped appropriately.  we then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  dissection was carried down to the level of the ribs with bovie electrocautery.  next, the ribs were counted and the 5th interspace was entered.  the lung was deflated.  we placed standard chest retractors.  next, we incised the peritoneum over the esophagus.  we dissected the esophagus to just above the azygos vein.  the azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  as mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  after doing this, we backed our ng tube out to above the level where we planned to perform our pursestring.  we used an automatic pursestring and applied.  we then transected the proximal portion of the stomach with metzenbaum scissors.  we secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  the pursestring was then tied down without difficulty.  next, we tabularized our stomach using a #80 gia stapler.  after doing so, we chose a portion of the stomach more distally and opened it using bovie electrocautery.  we placed our eea stapler through it and then punched out through the gastric wall.  we connected our anvil to the eea stapler.  this was then secured appropriately.  we checked to make sure that there was appropriate muscle apposition.  we then fired the stapler.  we obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  we also sent the gastroesophageal specimen for pathology.  of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  we then turned our attention to closing the gastrostomy opening.  this was closed with 2-0 vicryl in a running fashion.  we then buttressed this with serosal 3-0 vicryl interrupted sutures.  we returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  next, we placed two #28-french chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  we then closed the chest with #2 vicryl in an interrupted figure-of-eight fashion.  the lung was brought up.  we closed the muscle layers with #0 vicryl followed by #0 vicryl; then we closed the subcutaneous layer with 2-0 vicryl and the skin with 4-0 monocryl.  sterile dressing was applied.  the instrument and sponge count was correct at the end of the case.  the patient tolerated the procedure well and was extubated in the operating room and transferred to the icu in good condition."
+"preprocedure diagnosis:  change in bowel function. postprocedure diagnosis:  proctosigmoiditis. procedure performed:  colonoscopy with biopsy. anesthesia:  iv sedation. postprocedure condition:  stable.   indications:  the patient is a 33-year-old with a recent change in bowel function and hematochezia.  he is here for colonoscopy.  he understands the risks and wishes to proceed.   procedure:  the patient was brought to the endoscopy suite where he was placed in left lateral sims position, underwent iv sedation.  digital rectal examination was performed, which showed no masses, and a boggy prostate.  the colonoscope was placed in the rectum and advanced, under direct vision, to the cecum.  in the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis.  multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis. recommendations:  follow up with me in 2 weeks and we will begin canasa suppositories."
+"cc: stable expressive aphasia and decreased vision. hx: this 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. she was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. one month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. a hct (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. skull x-rays showed deviation of the pineal to the right. she was transferred to uihc and was noted to have a normal neurologic exam (per neurosurgery note). angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. she under went left temporal craniotomy and &quot;complete resection&quot; of the tumor which on pathologic analysis was consistent with a meningioma. the left sphenoid wing meningioma recurred and was excised 9/25/84. there was regrowth of this tumor seen on hct, 1985. a 6/88 hct revealed the left sphenoid meningioma and a new left tentorial meningioma. hct in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. on 2/14/91 she presented with increasing lethargy and difficulty concentrating. a 2/14/91, hct revealed increased size and surrounding edema of the left frontal meningioma. the left frontal and temporal meningiomas were excised on 2/25/91. these tumors all recurred and a left parietal lesion developed. she underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. the weakness partially resolved and though the speech improved following resection it did not return to normal. in may 1992 she experienced 3 tonic-clonic type seizures, all of which began with a jacksonian march up the rle then rue before generalizing. her phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. on 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. postoperatively she developed worsened right sided weakness and expressive aphasia. the weakness and aphasia improved by 3/93, but never returned to normal."
+"reason for referral:  the patient is a 76-year-old caucasian gentleman who works full-time as a tax attorney.  he was referred for a neuropsychological evaluation by dr. x after a recent hospitalization for possible transient ischemic aphasia.  two years ago, a similar prolonged confusional spell was reported as well.  a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. relevant background information:  historical information was obtained from a review of available medical records and clinical interview with the patient.  a summary of pertinent information is presented below.  please refer to the patient&#8217;s medical chart for a more complete history. history of presenting problem:  the patient was brought to the hospital emergency department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  he has no recollection of the event.  the following information is obtained from his medical record.  on 09/29/09, he reportedly went to a five-hour meeting and stated several times &quot;i do not feel well&quot; and looked &quot;glazed.&quot;  he does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  she thought he was warm and had chills.  he later returned to his baseline.  he was seen by dr. x in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  his neurological exam at that time was unremarkable aside from missing one of three items on recall for the mini-mental status examination.  due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  the patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  he was hospitalized at hospital at that time as well and evaluation included negative eeg, mri showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  he was also reportedly amnestic for this episode. in 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an mri at that time which showed some small vessel changes. during this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  he thought that his memory abilities were similar to those of his peers of his same age.  when i asked about this episode, he said he had no recall of it at all and that he &quot;felt fine the whole time.&quot;  he appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  so, the patient reported some age related &quot;memory lapses&quot; such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  however, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  he denied any missed appointments, any difficulty scheduling and maintaining appointments.  he does not have to recheck information for errors.  he is able to complete tasks in the same amount of time as he always has.  he reported that he has not made additional errors in tasks that he completed.  he said he does write everything down, but has always done things that way.  he reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  he did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  he remains completely independent in his adls.  he denied any difficulty with driving or maintaining any activities that he had always participated in.  he is also able to handle their finances.  he did report significant stress recently particularly in relation to his work environment. past medical history:  includes coronary artery disease, status post cabg in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by dr. y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  note that due to back pain, he had been taking percocet daily prior to his hospitalization. current medications:  celebrex 200 mg, levothyroxine 0.025 mg, vytorin 10/40 mg, lisinopril 10 mg, coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  note that medical records say that he was supposed to be taking lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine. other medical history:  surgical history is significant for hernia repair in 2007 as well.  the patient reported drinking an occasional glass of wine approximately two days of the week.  he quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  he denied any illicit drug use.  please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  he also had right carpal tunnel surgery in 2005 and has cholelithiasis.  upon discharge from the hospital, the patient&#8217;s sleep deprived eeg was recommended. mri completed on 09/30/09 showed &quot;mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated june 15, 2007.  no evidence of acute intracranial processes identified.  ct scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  eeg was negative.  deferential diagnosis was transient global amnesia versus possible seizure disorder.  note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid. family medical history: reportedly significant for tias in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  in addition, his father had a history of heart disease and passed away at the age of 75.  he has one sister with diabetes and thought his mom might have had diabetes as well. social history:  the patient obtained a law degree from the university of baltimore.  he did not complete his undergraduate degree from the university of maryland because he was able to transfer his credits in order to attend law school at that time.  he reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the bar.  he thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  he reported that he repeated math classes &quot;every year of school&quot; and attended summer school every year due to that.  he has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  he served also in the u.s.  coast guard between 1951 and 1953.  he has been married for the past 36 years to his wife, linda, who is a homemaker.  they have four children and he reported having good relationship with them.  he described being very active.  he goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends. psychiatric history:  the patient denied any history of psychological or psychiatric treatment.  he reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient. tasks administered:clinical interviewadult history questionnairewechsler test of adult reading (wtar)mini mental status exam (mmse)cognistat neurobehavioral cognitive status examinationrepeatable battery for the assessment of neuropsychological status (rbans; form xx)mattis dementia rating scale, 2nd edition (drs-2)neuropsychological assessment battery (nab)wechsler adult intelligence scale, third edition (wais-iii)wechsler adult intelligence scale, fourth edition (wais-iv)wechsler abbreviated scale of intelligence (wasi)test of variables of attention (tova)auditory consonant trigrams (act)paced auditory serial addition test (pasat)ruff 2 &#038; 7 selective attention testsymbol digit modalities test (sdmt)multilingual aphasia examination, second edition (mae-ii) token test sentence repetition visual naming controlled oral word association spelling test aural comprehension reading comprehensionboston naming test, second edition (bnt-2)animal naming testcontrolled oral word association test (cowat:  f-a-s)the beery-buktenica developmental test of visual-motor integration (vmi)the beery-buktenica developmental test of motor coordinationthe beery-buktenica developmental test of visual perceptionhooper visual organization test (vot)judgment of line orientation (jolo)rey complex figure test (rcft)wechsler memory scale, third edition (wms-iii)wechsler memory scale, fourth edition (wms-iv)california verbal learning test, second edition (cvlt-ii)rey auditory-verbal learning test (ravlt)delis-kaplan executive function system (d-kefs) trail making test verbal fluency (letter &#038; category) design fluency color-word interference test towerwisconsin card sorting test (wcst)stroop color-word testcolor trailstrail making test a &#038; bwide range achievement test, fourth edition (wrat-iv)woodcock johnson tests of achievement, third edition (wj-iii)nelson-denny reading testgrooved pegboardpurdue pegboardfinger tapping testbeck depression inventory (bdi)mood assessment scale (mas)state-trait anxiety inventory (stai)minnesota multiphasic personality inventory, second edition (mmpi-2)millon clinical multiaxial inventory, third edition (mcmi-iii)millon behavioral medicine diagnostic (mbmd)behavior rating inventory of executive function (brief)adaptive behavior assessment system, second edition (abas-ii) behavioral observations:  his wife arrived unaccompanied and on time for his appointment.  he was well-dressed and groomed and appeared younger than his stated age.  he ambulated independently and no gross psychomotor abnormalities were apparent.  eye contact was good.  speech was normal with respects to rate, rhythm, and paucity.  receptive language abilities appeared to be good as he was able to appropriately respond to the examiner&#8217;s questions and instructions.  thought processes were linear and goal-directed and no thought disturbances were noted.  mood appeared to be euthymic.  affect was appropriate and full range. vision and hearing appeared to be appropriate for the evaluation, although as noted, he apparently has some mild decline in his hearing that has not been addressed or evaluated.  overall, he was very friendly and rapport was very easily developed. he appeared to put full effort into all tasks and thus these results are thought to be an accurate reflection of his current cognitive functioning.  premorbid intellectual functioning; based on a word reading test, premorbid intellectual functioning was estimated to fall in the superior range.  he was notably impulse throughout the evaluation, as he would often try to begin a task before the examiner had completed providing instructions. cognitive functioning:  the patient was performed within the high average range on a measure of gross cognitive functioning assessing his performance across several domains including attention, visuospatial construction, memory conceptualization and initiation or perseveration.  he performed within normal limits on all these domains. attention:  passive and active auditory attention fell in the average range as he was able to accurately repeat six digits in forward sequence and five digits in backward sequence.  visual working memory was in the high average range.  on a test of sustained attention for visual stimuli, he demonstrated high rate of accuracy despite the fact that there was mild decreases in consistency of his responses as the task progressed and at different interstimulus intervals.  overall, however, these results appear to be well within normal limits.  thus taken together the patient&#8217;s auditory and nonverbal attentional abilities, all fell within normal limits and did not suggest significant decline from premorbid levels. language:  confrontation naming was strong and in the high average range.  he demonstrated good comprehension for verbal instructions.  he made a few very mild errors on a sentence repetition task, which may have been due to mild hearing problems.  the errors did not appear to be of clinical significance.  rapid verbal retrieval fell in the average range for both phonemic and semantic cues well within broad normal limits.  this result may have represented a mild weakness relative to his estimated premorbid functioning.  thus taken together, language abilities generally fell within the expected range, although mild weaknesses were seen in verbal fluency. visuospatial perception and construction:  visuospatial perception appeared to be within broad normal limits, although his construction and copy of visual figures was quite sloppy and imprecise. learning &#038; memory skills: verbal learning and memory:  on a contextual memory task (i.e. stories), the patient performed within the average range immediately following story presentation, as well as following a delay.  his recognition of story details was in the low average range.  when given a large amount of seemingly unorganized information (i.e.  16-item list), the patient&#8217;s initial ability to recall five-items immediately following presentation was in the average range.  he benefited significantly from repetition as he was able to recall 10 items following the second presentation and following a fifth presentation, he was able to successfully recall 13 of the 16 items (superior).  when immediately provided with a second list of 16-items, he was only able to recall three items immediately following presentation (low average).  his recall of the first list following short and long delays was in the average range.  delayed recognition was also average. of note, during his recalls, he made a large number of repetition errors suggesting some difficulty with self-monitoring of his responses.  he also did not recognize and apply any organizational strategy.  taken together, the patient&#8217;s performance across measures of verbal learning and memory fell within broad normal limits relative to others of same age.  however, given his very high level of premorbid functioning, his performance suggested some mild weaknesses in encoding and retrieval that he is generally able to overcome with repetition of information. he also appeared to have some difficulty organizing and monitoring his responses and difficulty with learning multiple simultaneous streams of information. non-verbal learning and memory:  the patient&#8217;s immediate recall of visual designs was in the borderline range.  however, he retained most of the information that he initially learned following a delay and his performance fell in the low average range.  recognition was average.  taken together, these results again suggest that he had difficulties with encoding and retrieval of nonverbal information.  however, he was able to retain most of the reduced amount of information that he had initially learned. executive functioning:  as mentioned, initiation and verbal fluency fell in the average range.  it is mildly weaker than expected given the patient&#8217;s strong premorbid functioning.  he was also noted to make a number of repetition errors on this task.  cognitive set shifting was generally within expected limits and in the average to high average range.  he was able to successfully inhibit a prepotent response.  on a task assessing cognitive flexibility inductive reasoning and the ability to use feedback in order to correct an ongoing response, the patient was noted to be quite impulsive and had difficulty conceptualizing alternate means to apply strategies in order to determine the correct answer and appeared to be somewhat distracted by nonessential information.  as mentioned above, he had a number of repetitions and difficulty organizing information meaningfully on memory tasks.  taken together, these results suggest mild weaknesses in aspects of frontal lobe functioning. motor functioning:  the patient performed in the average range with both of his right dominant hand and left nondominant hand on a speeded fine motor coordination task. emotional functioning:  on an affective screening measure, the patient endorsed only four items, which suggested that he was bothered by thoughts he could not get out of his head, often felt helpless, felt downhearted and blue and that his mind was not as clear as it used to be.  overall, these results fell within normal limits and suggest that he is not currently experiencing a clinical level of depressive symptoms. summary &#038; impressions:  the patient is a 76-year-old gentleman who was referred for a neuropsychological evaluation due to possible changes in memory.  he has a history of two episodes of confusion and amnesia, the most recent of which occurred in september 2009 with differential diagnosis including seizure disorder versus transient global amnesia.  on this comprehensive evaluation, the patient demonstrated mild weaknesses relative to his very high level of premorbid functioning on tasks assessing memory and executive functioning."
+"subjective:  the patient states that she feels better.  she is on iv amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  researching the available records, i find only an ems verbal statement that tachycardia of wide complex was seen.  there is no strip for me to review all available ekg tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm. the patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at abc medical center.  the aortic stenosis was secondary to a congenital bicuspid valve, by her description.  she states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  she has not had any decline in her postoperative period of her tolerance to exertion. the patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  last night, she had a prolonged episode for which she contacted ems.  her medications at home had been uninterrupted and without change from those listed, being toprol-xl 100 mg q.a.m., dyazide 25/37.5 mg, nexium 40 mg, all taken once a day.  she has been maintaining her crestor and zetia at 20 and 10 mg respectively.  she states that she has been taking her aspirin at 325 mg q.a.m.  she remains on zyrtec 10 mg q.a.m.  her only allergy is listed to latex. objective:vital signs:  temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  the patient shows a normal sinus rhythm on the telemetry monitor with an occasional pac.general:  she is alert and in no apparent distress.heent:  eyes:  eomi.  perrla.  sclerae nonicteric.  no lesions of lids, lashes, brows, or conjunctivae noted.  funduscopic examination unremarkable.  ears:  normal set, shape, tms, canals and hearing.  nose and sinuses:  negative.  mouth, tongue, teeth, and throat:  negative except for dental work.neck:  supple and pain free without bruit, jvd, adenopathy or thyroid abnormality.chest:  lungs are clear bilaterally to auscultation.  the incision is well healed and without evidence of significant cellulitis.heart:  shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  there is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.abdomen:  soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.extremities:  show no evidence of dvt, acute arthritis, cellulitis or pedal edema.neurologic:  nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  gait and station were not tested.mental status:  shows the patient to be alert, coherent with full capacity for decision making.back:  negative to inspection or percussion. laboratory data:  shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  inr 1.0.  electrolytes are normal with exception potassium 3.3.  gfr is decreased at 50 with creatinine of 1.1.  glucose was 119.  magnesium was 2.3.  phosphorus 3.8.  calcium was slightly low at 7.8.  the patient has had ionized calcium checked at munson that was normal at 4.5 prior to her discharge.  troponin is negative x2 from 2100 and repeat at 07:32.  this morning, her bnp was 163 at admission.  her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  her current ekg tracing from 05:42 shows a sinus bradycardia with wolff-parkinson white pattern, a rate of 58 beats per minute, and a corrected qt interval of 557 milliseconds.  her pr interval was 0.12. we received a call from munson medical center that a bed had been arranged for the patient.  i contacted dr. varner and we reviewed the patient&#8217;s managed to this point.  all combined impression is that the patient was likely to not have had actual ventricular tachycardia.  this is based on her ep study from october showing her to be non-inducible.  in addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  what is most likely that the patient has postoperative atrial fibrillation.  her wpw may have degenerated into a ventricular tachycardia, but this is unlikely.  at this point, we will convert the patient from iv amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  i will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  dr. varner will be making arrangements for an outpatient holter monitor and further followup post-discharge. impression:1.  atrial fibrillation with rapid ventricular response.2.  wolff-parkinson white syndrome.3.  recent aortic valve replacement with bioprosthetic medtronic valve.4.  hyperlipidemia."
+"history of present illness:  mr. a is a 50-year-old gentleman with a history of atrial fibrillation in the past, more recently who has had atrial flutter, who estimates he has had six cardioversions since 10/09, and estimates that he has had 12 to 24 in his life beginning in 2006 when the atrial fibrillation first emerged.  he, since 10:17 p.m. on 01/17/10, noted recurrence of his atrial fibrillation, called our office this morning, that is despite being on flecainide, atenolol, and he is maintained on coumadin. the patient has noted some lightheadedness as well as chest discomfort and shortness of breath when atrial flutter recurred and we see that on his 12-lead ekg here.  otherwise, no chest pain. past medical history:  significant for atrial fibrillation/atrial flutter and again he had atrial fibrillation more persistently in 2006, but more recently it has been atrial flutter and that is despite use of antiarrhythmics including flecainide.  he completed a stress test in my office within the past several weeks that was normal without evidence of ischemia.  other medical history is significant for hyperlipidemia. medications:as outpatient,1.  atenolol 25 mg once a day.2.  altace 2.5 mg once a day.3.  zocor 20 mg once a day.4.  flecainide 200 in the morning and 100 in the evening.5.  coumadin as directed by our office. allergies:  to medications are none.  he denies shrimp, sea food or dye allergy. family history:  he has a nephew who was his sister&#8217;s son who passed away at age 22 reportedly from an mi, but was reported to have hypertrophic cardiomyopathy as well.  the patient has previously met with the electrophysiologist, dr. x, at general hospital and it sounds like he had a negative ep study. social history:  the patient does not smoke cigarettes, abuse alcohol nor drink any caffeine.  no use of illicit drugs.  he has been married for 22 years and he is actually accompanied throughout today&#8217;s cardiology consultation by his wife.  he is not participating in regular exercises now because he states since starting flecainide, he has gotten sluggish.  he is employed as an attorney and while he states that overall his mental stress is better, he has noted more recent mental stress this past weekend when he was taking his daughter back to college. review of systems:  he denies any history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi.  there are some questions especially as his wife has told me that he may have obstructive sleep apnea and not had a formal sleep study. physical exam:  blood pressure 156/93, pulse is 100, respiratory rate 18.  on general exam, he is a pleasant overweight gentleman, in no acute distress.  heent:  shows cranium is normocephalic and atraumatic.  he has moist mucosal membranes.  neck veins are not distended.  there are no carotid bruits.  visible skin warm and perfused.  affect appropriate.  he is quite oriented and pleasant.  no significant kyphoscoliosis on recumbent back exam.  lungs are clear to auscultation anteriorly.  no wheezes.  no egophony.  cardiac exam:  s1, s2.  regular rate, controlled.  no significant murmurs, rubs or gallops.  pmi is nondisplaced.  abdomen is soft, nondistended, appears benign.  extremities without significant edema.  pulses grossly intact. diagnostic studies/lab data:  initial ecg shows atrial flutter. impression:  mr. a is a 50-year-old gentleman with a history of paroxysmal atrial fibrillation in the past, more recently is having breakthrough atrial flutter despite flecainide and we had performed a transesophageal echocardiogram-guided cardioversion for him in late 12/20/09, who now has another recurrence within the past 41 hours or so.  i have reviewed again with him in detail regarding risks, benefits, and alternatives of proceeding with cardioversion, which the patient is in favor of.  after in depth explanation of the procedure with him that there would be more definitive resumption of normal sinus rhythm by using electrocardioversion with less long-term side effects, past the acute procedure, alternatives being continued atrial flutter with potential for electrophysiologic consultation for ablation and/or heart rate control with anticoagulation, which the patient was not interested nor was i primarily recommending as the next step, and risks including, but not limited to and the patient was aware and this was all done in the presence of his wife that this is not an all-inclusive list, but the risks include but not limited to oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, which would be less likely as i did confirm with the patient that he had been n.p.o. for greater than 15 hours, risk of induction of other arrhythmias including tachyarrhythmias requiring further management including cardioversion or risk of bradyarrhythmias, in the past when we had a cardioverter with 150 joules, he did have a 5.5-second pause especially while he is on antiarrhythmic therapy, statistically less significant risk of cva, although we cannot really make that null.  the patient expressed understanding of this risk, benefit, and alternative analysis.  i invited questions from him and his wife and once their questions were answered to their self-stated satisfaction, we planned to go forward with the procedure. procedure note:  the patient received a total of 7 mg of versed and 50 micrograms of fentanyl utilizing titrate-down sedation with good effect and this was after the appropriate time-out procedure had been done as per the medical center universal protocol with appropriate identification of the patient, position, procedure documentation, procedure indication, and there were no questions.  the patient did actively participate in this time-out procedure.  after the universal protocol was done, he then received the cardioversion attempt with 50 joules using &quot;lollipop posterior patch&quot; with hands-driven paddle on the side, which was 50 joules of synchronized biphasic energy.  there was successful resumption of normal sinus rhythm, in fact this time there was not a significant pause as compared to when he had this done previously in late 12/09 and this sinus rhythm was confirmed by a 12-lead ekg. impression:  cardioversion shows successful resumption of normal sinus rhythm from atrial flutter and that is while the patient has been maintained on coumadin and his inr is 3.22.  we are going to watch him and discharge him from the medical center area on his current flecainide of 200 mg in the morning and 100 mg in the evening, atenolol 25 mg once a day, coumadin _____ as currently being diagnosed.  i had previously discussed with the patient and he was agreeable with meeting with his electrophysiologist again, dr. x, at electrophysiology unit at general hospital and i will be planning to place a call for dr. x myself.  again, he has no ischemia on this most recent stress test and i suppose in the future it may be reasonable to get obstructive sleep apnea evaluation and that may be one issue promulgating his symptoms. i had previously discussed the case with dr. y who is the patient&#8217;s general cardiologist as well as updated his wife at the patient&#8217;s bedside regarding our findings."
+"history of present illness:  hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by dr. x of cardiology through most of the day.  this afternoon, when i am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a map of 52.  dr. x was again consulted from the bedside.  we agreed to try fluid boluses and then to consider neo-synephrine pressure support if this is not successful.  in addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient&#8217;s possible move to tahoe pacific or a long-term acute care.  other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-st-elevation mi, hypernatremia, chronic obstructive pulmonary disease, bph, atrial flutter, inferior vena cava filter, and diabetes. physical examinationvital signs:  t-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a map of 52, heart rate is 100.general:  the patient is much more alert appearing than my last examination of approximately 3 weeks ago.  he denies any pain, appears to have intact mentation, and is in no apparent distress.eyes:  pupils round, reactive to light, anicteric with external ocular motions intact.cardiovascular:  reveals an irregularly irregular rhythm.lungs:  have diminished breath sounds but are clear anteriorly.abdomen:  somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.extremities:  show trace edema with no clubbing or cyanosis.neurological:  the patient is moving all extremities without focal neurological deficits. laboratory data:  sodium 149; this is down from 151 yesterday.  potassium 3.9, chloride 114, bicarb 25, bun 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, wbc 16.5, platelets 231,000.  inr 1.4.  transaminases are continuing to trend upwards of sgot 546, sgpt 256.  also noted is a scant amount of very concentrated appearing urine in the bag. impression:  overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate. plan1.  hypotension.  i would aggressively try and fluid replete the patient giving him another liter of fluids.  if this does not work as discussed with dr. x, we will start some neo-synephrine, but also continue with aggressive fluid repletion as i do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.2.  increased transaminases.  presumably this is from increased congestion.  this is certainly concerning.  we will continue to follow this.  ultrasound of the liver was apparently negative.3.  fever and elevated white count.  the patient does have a history of pneumonia and empyema.  we will continue current antibiotics per infectious disease and continue to follow the patient&#8217;s white count.  he is not exceptionally toxic appearing at this time.  indeed, he does look improved from my last examination.4.  ventilatory-dependent respiratory failure.  the patient has received a tracheostomy since my last examination.  vent management per pma.5.  hypokalemia.  this has resolved.  continue supplementation.6.  hypernatremia.  this is improving somewhat.  i am hoping that with increased fluids this will continue to do so.7.  diabetes mellitus.  fingerstick blood glucoses are reviewed and are at target.  we will continue current management.  this is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  total critical care time spent today 37 minutes."
+"reason for visit:  acute kidney failure. history of present illness:  the patient is a 68-year-old korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage iii ckd with a creatinine of 1.8 in may 2006 corresponding with the gfr of 40-41 ml/min.  the patient had blood work done at dr. xyz&#8217;s office on june 01, 2006, which revealed an elevation in his creatinine up to 2.3.  he was asked to come in to see a nephrologist for further evaluation.  i am therefore asked by dr. xyz to see this patient in consultation for evaluation of acute on chronic kidney failure.  the patient states that he was actually taking up to 12 to 13 pills of chinese herbs and dietary supplements for the past year.  he only stopped about two or three weeks ago.  he also states that tricor was added about one or two months ago but he is not sure of the date.  he has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on flomax.  he states that his urinary dribbling and weak stream had not improved since doing this.  for the past couple of weeks, he has had dizziness in the morning.  this is then associated with low glucose.  however the patient&#8217;s blood glucose this morning was 123 and he still was dizzy.  this was worse on standing.  he states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions.  his pulses remained in the 60s. allergies:  none. medications:  imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, zetia 10 mg daily, ? triglide 50 mg daily, prevacid 30 mg daily, plavix 75 mg daily, potassium 10 meq daily, lasix 60 mg daily, folate 1 mg b.i.d., niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., xanax 0.25 mg b.i.d., aspirin 325 mg daily, tylenol p.r.n., zantac 150 mg b.i.d., crestor 5 mg daily, tricor 145 mg daily, digitek 0.125 mg daily, celexa 20 mg daily, and flomax 0.4 mg daily. past medical history:1.  coronary artery disease status post cabg x 5 in december 2001.2.  three stents last placed approximately 2002.3.  heart failure, ejection fraction of 30%.4.  hypertension since 1985.5.  diabetes since 1985 with history of laser surgery.6.  moderate mitral regurgitation.7.  gi bleed.8.  hyperlipidemia.9.  bph.10.  back surgery.11.  sleep apnea. social history:  he is a former tailor from korea.  he is divorced.  he has one daughter who has brain injury status post severe seizure as a child.  he is the primary caregiver.  no drug abuse.  he quit tobacco and alcohol 15 years ago. family history:  parents both died in korea.  has one sister with hypertension and the other sister lives in detroit and is healthy. review of systems:  he has lost about 10 pounds over the past month.  he has been fatigue and weak with no appetite.  he has occasional chest pain and dyspnea on exertion on fast walking.  his lower extremity edema has improved with higher doses of furosemide.  he does complain of some early satiety.  he complains of urinary frequency, nocturia, weak stream and dribbling.  he has never passed the stone.  he gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s.  he has some right back pain today and complains of farsightedness.  the remainder of review of systems is done and negative per the patient. physical examination:  vital signs:  pulse 78.  blood pressure 116/60.  height 5&#8217;7&quot; per the patient.  weight 78.6 kg.  supine pulse 60 with blood pressure 128/55.  standing pulse 60 with blood pressure of 132/50.  general:  he is in no apparent distress, but he is dizzy on standing for prolonged period.  eyes:  pupils equal, round and reactive to light.  extraocular movements are intact.  sclerae not icteric.  heent:  he wears upper and lower dentures.  lips acyanotic.  hearing is grossly intact.  oropharynx is otherwise clear.  neck:  supple.  no jvd.  no bruits.  no masses.  heart:  regular rate and rhythm.  no murmurs, rubs or gallops.  lungs:  clear bilaterally.  abdomen:  active bowel sounds.  soft, nontender, and nondistended.  no suprapubic tenderness.  extremities:  no clubbing, cyanosis or edema.  musculoskeletal:  5/5 strength bilaterally.  no synovitis, arthritis or gait disturbance.  skin:  old scars in his low back as well as his left lower extremity.  no active rashes, purpura or petechiae.  midline sternotomy scar is well healed.  neurologic:  cranial nerves ii through xii are intact.  reflexes are poor to 1+ bilaterally.  10 g monofilament sensation is intact except for the big toes bilaterally.  no asterixis.  finger-to-nose testing is intact.  psychiatric:  fully alert and oriented. laboratory data:  december 2004, creatinine was 1.5.  per report may 2006, creatinine was 1.8 with a bun of 28.  labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, co2 25, bun 46, creatinine 2.3, glucose 162, albumin 4.7, lfts are normal.  ck was elevated at 653.  a1c is 7.6%.  ldl cholesterol is 68, hdl is 35.  urinalysis reveals microalbumin to creatinine ratio 59.8.  ua was otherwise negative with a ph of 5.  today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dl of protein, ph of 5, negative nitrates, leukocyte esterase.  microscopic exam was bland. impression:1.  acute on chronic kidney failure.  he has underlying stage iii ckd with the gfr approximately 41 ml/min.  he has episodic hypotension at home and low diastolic pressure here.  his weight is down 2 to 3 kg from june and he may be prerenal.  he also has a history of prostatic hypertrophy and obstruction must be investigated.  i am also concerned about his use of chinese herbs which can cause chronic interstitial nephritis.  there is no evidence of pyuria today although this can present with a fairly bland sediment.  an additional concern is that tricor can cause an artifactual increase in the creatinine due to changes in metabolism.  i think this would be a diagnosis of exclusion.2.  orthostatic hypotension.  he is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.3.  elevated creatine kinase consistent with myositis.  it could be a result of crestor alone or combination of tricor and crestor.  i do not think this is enough to cause rhabdomyolysis, however. recommendations:1.  the patient was cautioned about using nsaids and told to avoid any further chinese herbs.2.  recheck labs including cbc with differential, spep, uric acid and renal panel.3.  decrease atenolol to 25 mg daily.4.  decrease enalapril to 10 mg daily.5.  decrease lasix to 20 mg daily.6.  stop crestor.7.  check renal ultrasound.8.  see him back in two weeks for review of the studies."
+"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&#8217;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&#8217;s cardiac medication should be continued if the patient is allowed p.o. intake.2.  the patient should have gastroenterology and surgical consultation evaluation.3.  the patient can have an echocardiogram performed with cardiac function at this stage.  the patient will be in a mild-to-moderate cardiovascular risk should she need any surgery and anesthesia due to all her above comorbid problems as mentioned.4.  dr. c will follow this patient in my absence over the next 3-4 days.5.  additional recommendations will follow if needed."
+"exam:  coronary artery cta with calcium scoring and cardiac function. history:  chest pain. technique and findings:  coronary artery cta was performed on a siemens dual-source ct scanner.  post-processing on a vitrea workstation.  150 ml ultravist 370 was utilized as the intravenous contrast agent.  patient did receive nitroglycerin sublingually prior to the contrast. history:  significant for high cholesterol, overweight, chest pain, family history patient&#8217;s total calcium score (agatston) is 10. his places the patient just below the 75th percentile for age. the lad has a moderate area of stenosis in its midportion due to a focal calcified plaque.  the distal lad was unreadable while the proximal was normal.  the mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  the circumflex is diminutive in size along its proximal portion.  distal is not readable. cardiac wall motion within normal limits.  no gross pulmonary artery abnormality however they are not well delineated.  a full report was placed on the patient&#8217;s chart.  report was saved to pacs."
+"informed consent was obtained after explanation of the procedure, as well as risk factors of bleeding, perforation, adverse medication reaction. the patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation. the olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum. findings:esophagus:  proximal and mid esophagus were without abnormalities.stomach:  insufflated and retroflexed visualization of the gastric cavity revealedduodenum:  normal."
+"procedures performed:1. left heart catheterization with coronary angiography and left ventricular pressure measurement.2. left ventricular angiography was not performed.3. right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.4. right femoral artery angiography.5. perclose to seal the right femoral arteriotomy. indications for procedure: patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. the patient presented with what appeared to be a copd exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-st elevation myocardial infarction. he was subsequently dispositioned to the cardiac catheterization lab for further evaluation. description of procedure: after informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. the patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. then, a 6-french sheath was inserted into the right femoral artery. over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-french jl4 diagnostic catheter to image the left coronary artery, a 6-french jr4 diagnostic catheter to image the right coronary artery, a 6-french angled pigtail catheter to measure left ventricular pressure. at the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. then, a perclose was used to seal the right femoral arteriotomy. hemodynamic data: the opening aortic pressure was 91/63. the left ventricular pressure was 94/13 with an end-diastolic pressure of 24. left ventricular ejection fraction was not assessed, as ventriculogram was not performed. the patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible. coronary angiogram: the left main coronary artery was angiographically okay. the lad had mild diffuse disease. there appeared to be distal tapering of the lad. the left circumflex had mild diffuse disease. in the very distal aspect of the circumflex after om-3 and om-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. the runoff from this area appeared to be a very small plom type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. the right coronary artery had mild diffuse disease. the plv branch was 100% occluded at its ostium at the crux. the pda at the ostium had an 80% stenosis. the pda was a fairly sizeable vessel with a long course. the right coronary is dominant. conclusion: mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. this circumflex appears to be chronically diseased and has areas that appear to be subtotal. there is a 100% plv branch which is also chronic and reported in his angiogram in the 1990s. there is an ostial 80% right pda lesion. the plan is to proceed with percutaneous intervention to the right pda. the case was then progressed to percutaneous intervention of the right pda. a 6-french jr4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. the lesion was crossed with a long bmw 0.014 guidewire. then, we ballooned the lesion with a 2.5 x 9 mm maverick balloon. subsequently, we stented the lesion with a 2.5 x 16 mm taxus drug-eluting stent with a nice angiographic result. the patient tolerated the procedure very well, without complications. angioplasty conclusion: successful percutaneous intervention with drug-eluting stent placement to the ostium of the pda. recommendations: aspirin indefinitely, and plavix 75 mg p.o. daily for no less than six months. the patient will be dispositioned back to telemetry for further monitoring. total medications during procedure: versed 1 mg and fentanyl 25 mcg for conscious sedation. heparin 8400 units iv was given for anticoagulation. ancef 1 g iv was given for closure device prophylaxis. contrast administered: 200 ml. fluoroscopy time: 12.4 minutes."
+"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&#8217;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."
+"<strong>procedure:</strong> bronchoscopy, right upper lobe biopsies and right upper lobe bronchial washing as well as precarinal transbronchial needle aspiration. <strong>details of the procedure: </strong>the risks, alternatives, and benefits of the procedure were explained to the patient as well as conscious sedation and she agrees to proceed. the patient received topical lidocaine by nebulization. the flexible fiberoptic bronchoscope was introduced orally. the patient had normal teeth, normal tongue, normal jaw, and her vocal cords moved symmetrically and were without lesions. i proceeded to the right upper lobe where a mucous plug was noted in the subsegmental bronchus of the posterior segment of the right upper lobe. i proceeded under fluoroscopic guidance to guide the biopsy wire in this area and took four biopsies. followup fluoroscopy was negative for pneumothorax. i wedged the bronchoscope in the subsegmental bronchus and achieved good hemostasis after three minutes. i then proceeded to inspect the rest of the tracheobronchial tree, which was without lesions. i performed a bronchial washing after the biopsies in the right upper lobe. i then performed two transbronchial needle aspirations with a wang needle biopsy in the precarinal area. all of these samples were sent for histology and cytology respectively. estimated blood loss was approximately 5 cc. good hemostasis was achieved. the patient received a total of 12.5 mg of demerol and 3 mg of versed and tolerated the procedure well. her asa score was 2."
+"<strong>procedures: </strong>left heart catheterization, left ventriculography, and left and right coronary arteriography. <strong>indications: </strong>chest pain and non-q-wave mi with elevation of troponin i only. <strong>technique: </strong>the patient was brought to the procedure room in satisfactory condition. the right groin was prepped and draped in routine fashion. an arterial sheath was inserted into the right femoral artery. left and right coronary arteries were studied with a 6fl4 and 6fr4 judkins catheters respectively. cine coronary angiograms were done in multiple views. left heart catheterization was done using the 6-french pigtail catheter. appropriate pressures were obtained before and after the left ventriculogram, which was done in the rao view. at the end of the procedure, the femoral catheter was removed and angio-seal was applied without any complications. <strong>findings:</strong> 1. lv is normal in size and shape with good contractility, ef of 60%. 2. lmca normal. 3. lad has 20% to 30% stenosis at the origin. 4. lcx is normal. 5. rca is dominant and normal. <strong>recommendations: </strong>medical management, diet, and exercise. aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. follow up in the clinic."
+"reason for consultation:  management of pain medications. history of present illness:  this is a 60-year-old white male with history of coronary artery disease, status post cabg in 1985 with subsequent sternal dehiscence with rewiring in december 2005 and stent placement in lad region in 2005, who developed sudden chest pain and was taken to san jacinto via ambulance where he was diagnosed with acute mi and then went into atrial fibrillation.  an intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the abcd hospital on october 22, 2006, for continued critical care.  he was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  he is currently on dialysis due to end-stage renal disease and has a tracheostomy.  he is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  he states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  he currently rates his pain as 7 out of 10.  he denies a depressed mood or anxiety and states that he knows he is getting better.  he describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl iv and then will wake up until he gets another fentanyl.  he has peg for tube feeding.  he has weakness on left side of his body as well as both legs since his mi.  he has been switched from fentanyl iv q.2h. to the fentanyl patch today.  he also has been started on seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of monday, february 12, 2007.  he denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  his wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems. past medical history:1.  dvt in december 2005.2.  three mi&#8217;s (1996, 2005, and 2006).3.  diabetes for 5 years.4.  coronary artery disease for 10 years. past surgeries:1.  appendectomy as a child.2.  cabg x3, november 2005.3.  sternal rewiring, december 2005. medications:1.  restoril 7.5 mg p.o. at bedtime p.r.n.2.  acetaminophen 650 mg p.o. q.6h. p.r.n. fever.3.  aspirin 81 mg p.o. daily.4.  bisacodyl suppository 10 mg per rectum daily.5.  erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.6.  esomeprazole 40 mg iv q.12h.7.  fentanyl patch 25 mcg per hour.8.  transderm patch every 72 hours.9.  heparin iv.10.  lactulose 30 ml p.o. daily p.r.n. constipation.11.  metastron injection 4 mg iv q.6h. p.r.n. nausea.12.  seroquel 12 mg p.o. at bedtime.13.  saliva substitute 30 ml spray p.o. q.3h. p.r.n. dry mouth.14.  simethicone drops 80 mg per g-tube p.r.n. gas pain.15.  bactrim suspension p.o. daily.16.  insulin medium dose sliding scale.17.  albumin 25% iv p.r.n. hemodialysis.18.  ipratropium solution for nebulizer. allergies:  no known drug allergies. past psychiatric history:  the patient denies any past psychiatric problems.  no medications.  he denies any outpatient visits or inpatient hospitalizations for psychiatric reasons. social history:  he lives with his wife in new jersey.  he has 2 children.  one son in texas city and 1 daughter in florida.  he is a master mechanic for a trucking company since 1968.  he retired in the may 2006.  the highest level of education that he received was 1 year in college. ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  he occasionally has a beer, but denies any continuous use of alcohol.  he denies any illicit drug use. family history:  both parents died with myocardial infarctions.  he has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  he denies any history of psychiatric problems in family. mental status examination:  the patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  the patient&#8217;s appearance was appropriate with fair-to-good grooming and hygiene.  he had little-to-no psychomotor activity secondary to weakness post mi.  he had good eye contact.  his speech was of decreased rate volume and flexion secondary to tracheostomy.  the patient was cooperative.  he described his mood is not good in congruent stable and appropriate affect with decreased range.  his thought process is logical and goal directed.  his thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  he denied any perceptional disturbances including any auditory or visual hallucinations.  he was alert and oriented x3. mini mental status exams not completed. assessment:axis i:  pain with physical symptoms and possibly psychological symptoms.axis ii:  deferred.axis iii:  see above.axis iv:  stress associated with medical illnesses.axis v:  gaf indeterminate. this is a 60-year-old white male with history of coronary artery disease, recurrent mi&#8217;s, diabetes mellitus, and dvt who has experienced multiorgan failure secondary to cardiogenic shock, complaining of pain, and inability to sleep secondary to pain. plan:1.  the patient and his wife were surprised to see that psychiatry was consultant and did not seem to be happy to see us.2.  the patient has agreed to discuss in psychiatric consultation with dr. abc and we will be called if we can be of any further assistance. thank you for consulting."
+"history of present illness:  the patient is a 41-year-old african-american male previously well known to me.  he has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  there is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  he has a previous history of transient ischemic attack with no residual neurologic deficits. the patient has undergone surgery by dr. x for attempted nephrolithotomy.  the patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  the patient is presently seen at the request of dr. x for management of anticoagulation and his above heart disease. past medical and surgical history:1.  type i diabetes mellitus.2.  hyperlipidemia.3.  hypertension.4.  morbid obesity.5.  sleep apnea syndrome.6.  status post thyroidectomy for thyroid carcinoma. review of systems:general:  unremarkable.cardiopulmonary:  no chest pain, shortness of breath, palpitations, or dizziness.gastrointestinal:  unremarkable.genitourinary:  see above.musculoskeletal:  unremarkable.neurologic:  unremarkable. family history:  there are no family members with coronary artery disease.  his mother has congestive heart failure. social history:  the patient is married.  he lives with his wife.  he is employed as a barber.  he does not use alcohol, tobacco, or illicit drugs. medications prior to admission:1.  clonidine 0.3 mg b.i.d.2.  atenolol 50 mg daily.3.  simvastatin 80 mg daily.4.  furosemide 40 mg daily.5.  metformin 1000 mg b.i.d.6.  hydralazine 25 mg t.i.d.7.  diovan 320 mg daily.8.  lisinopril 40 mg daily.9.  amlodipine 10 mg daily.10.  lantus insulin 50 units q.p.m.11.  kcl 20 meq daily.12.  novolog sliding scale insulin coverage.13.  warfarin 7.5 mg daily.14.  levothyroxine 0.2 mg daily.15.  folic acid 1 mg daily. allergies:  none. physical examination:general:  a well-appearing, obese black male.vital signs:  bp 140/80, hr 88, respirations 16, and afebrile.heent:  grossly normal.neck:  normal.  thyroid, normal.  carotid, normal upstroke, no bruits.chest:  midline sternotomy scar.lungs:  clear.heart:  pmi fifth intercostal space mid clavicular line.  normal s1 and prosthetic s2.  no murmur, rub, gallop, or click.abdomen:  soft and nontender.  no palpable mass or hepatosplenomegaly.extremities:  normal.  no edema.  pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis.neurologic:  mental status, no gross cranial nerve, motor, or sensory deficits. electrocardiogram:  normal sinus rhythm.  right bundle-branch block.  findings compatible with old anteroseptal and lateral wall myocardial infarction._______ nonspecific st-t abnormality. impression:1.  status post nephrolithotomy with postoperative hematuria.2.  aortic valve disease, status post aortic valve replacement on 10/15/2007.3.  congestive heart failure, diastolic, chronic, stable, nysha class i to ii.4.  paroxysmal atrial fibrillation.5.  status post remote transient ischemic attack with no residual neurologic deficits.6.  type i diabetes mellitus.7.  hyperlipidemia.8.  hypertension.9.  morbid obesity.10.  sleep apnea syndrome.11.  chronic therapeutic anticoagulation. recommendations:  until resolution of the hematuria, i agree with the necessity of discontinuation of all anticoagulation.  there is obvious risk both due to prosthetic aortic valve and paroxysmal atrial fibrillation with continuation of anticoagulation; however, the risk of uncontrolled bleeding is essentially worse.continue other medications."
+"history of present illness:  this is a 23-year-old married man who had an onset of aplastic anemia in december, underwent a bone marrow transplant in the end of march, has developed very severe graft-versus-host reaction.  psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior. the patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in abcd that was about two years ago.  gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then.  prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could.  he would drink up to half of a fifth of rum on a daily basis when available. the patient is currently on lexapro 10 mg in the morning and diazepam 10 mg at bedtime.  he complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments.  he would have a limited support system here in colorado.  he married in january and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in july.  i would recommend some couples counseling as a part of their treatment here. the patient was fairly drowsy during the interview and full past and developmental history was not obtained.  the patient&#8217;s comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in xyz area because he did not like school. physical examination:  general:  this is a cooperative man, speech is soft and difficult to understand.  there is no thought disorder and no hallucination.  he denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.vital signs:  temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.psychiatry:  there is no thought disorder, no paranoia, no delusions, and no psychotic symptoms.  activities of daily living (adls) appear intact.  on formal testing, he is oriented to place.  he can give a reasonable recitation of his medical history.  he is oriented to the year, knows it is the 15th, but gave the month as june instead of may.  he can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits.  he can do serial three subtractions accurately, can name objects appropriately. laboratory data:  sodium of 135, bun of 24, and glucose 119.  ggt of 355, alt of 97, ldh of 703, and alk phos of 144.  fk506 is 28.8, which is elevated tacrolimus level.  hematocrit 29% and white count is 7000. diagnoses:  axis i:  depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.axis ii:  personality disorder, not otherwise specified (nos).axis iii:  history of polysubstance abuse, in remission. recommendations:  1.  this patient appears to retain the ability to make decisions on his own behalf.  i think he is mentally competent.  unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness.  if the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.2.  the patient does complain of depressed mood, also of anxiety.  we did discuss medications.  he appeared somewhat sedated at the time of my interview.  i would recommend that we try seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety.  i will have dr. x followup with him. please feel free to contact me at digital pager if additional information is needed. my overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this."
+"cc: falls. hx: this 51y/o rhf fell four times on 1/3/93, because her &quot;legs suddenly gave out.&quot; she subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. during some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. during one episode she held her rue in an &quot;odd fisted posture.&quot; she denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. she did not seek medical attention despite her weakness. then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to uihc for evaluation on 1/5/93. meds: micronase 5mg qd, hctz, quit asa 6 months ago (tired of taking it). pmh: 1)dm type 2, dx 6 months ago. 2)htn. 3)djd. 4)s/p vitrectomy and retinal traction ou for retinal detachment 7/92. 5) s/p cholecystemomy,1968. 6) cataract implant, ou,1992. 7) s/p c-section. fhx: grand aunt (stroke), mg (cad), mother (cad, died mi age 63), father (with unknown ca), sisters (htn), no dm in relatives. shx: married, lives with husband, 4 children alive and well. denied tobacco/etoh/illicit drug use. ros: intermittent diarrhea for 20 years. exam: bp164/82 hr64 rr18 36.0c ms: a &#038; o to person, place, time. speech fluent and without dysarthria. intact naming, comprehension, reading. cn: pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. optic disks flat. eom intact. vfftc. right lower facial weakness. the rest of the cn exam was unremarkable. motor: 5/5 bue with some question of breakaway. le: hf and he 4+/5, kf5/5, af and ae 5/5. normal muscle bulk and tone. sensory: intact pp/vib/prop/lt/t/graphesthesia. coord: slowed fnf and hks (worse on right). station: no pronator drift or romberg sign. gait: unsteady wide-based gait. unable to heel walk on right. reflexes: 2/2+ throughout (slightly more brisk on right). plantar responses were downgoing bilaterally. heent: n0 carotid or cranial bruits. gen exam: unremarkable. course: cbc, gs (including glucose), pt/ptt, ekg, cxr on admission, 1/5/93, were unremarkable. hct, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. carotid duplex: 0-15%rica, 16-49%lica; antegrade vertebral artery flow, bilaterally. transthoracic echocardiogram showed borderline lv hypertrophy and normal lv function. no valvular abnormalities or thrombus were seen. the patient&#8217;s history and exam findings of right facial and rle weakness with sparing of the rue would invoke a raca territory stroke with recurrent artery of heubner involvement causing the facial weakness."
+"doctor&#8217;s namedoctor&#8217;s address dear doctor: this letter serves as an introduction to my patient, a, who will be seeing you in the near future.  he is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  he has been treated by dr. x through the pediatric neurology clinic.  he saw dr. x recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  she also noted and confirmed that he has significant tonsillar hypertrophy.  the concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  therefore, i ask for your opinion on this matter. for his chronic allergic rhinitis symptoms, he is currently on flonase two sprays to each nostril once a day.  he also has been taking zyrtec 10 mg a day with only partial relief of the symptoms.  he does have an allergy to penicillin. i appreciate your input on his care.  if you have any questions regarding, please feel free to call me through my office.  otherwise, i look forward to hearing back from you regarding his evaluation."
+"single chamber pacemaker implantation preoperative diagnosis:  mobitz type ii block with av dissociation and syncope. postoperative diagnosis:  mobitz type ii block, status post single chamber pacemaker implantation, boston scientific altrua 60, serial number 123456. procedures:1.  left subclavian access under fluoroscopic guidance.2.  left subclavian venogram under fluoroscopic evaluation.3.  insertion of ventricular lead through left subclavian approach and ventricular lead is boston scientific dextrose model 4136, serial number 123456.4.  insertion of single-chamber pacemaker implantation, altrua, serial number 123456.5.  closure of the pocket after formation of pocket for pacemaker. procedure in detail:  the procedure was explained to the patient with risks and benefits.  the patient agreed and signed the consent form.  the patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of benadryl for conscious sedation. access to the right subclavian was successful after the second attempt.  the first attempt accessed the left subclavian artery.  the needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  the j-wire was introduced into the left subclavian vein. the anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used. the pocket was formed using blunt dissection as he was using the bovie cautery for hemostasis.  the patient went asystole during the procedure.  the transcutaneous pacer was used.  the patient was oxygenating well.  the patient had several compression applied by the nurse.  however, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby. after that, the j-wire was tunneled into the pocket and then used to put the #7-french sheath into the left subclavian vein.  the lead from the boston scientific dextrose model 4136, serial number 28520361 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 ml of contrast to assess the subclavian and the right atrium.  the findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  at that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place. at that point, the lead was actively fixated.  the stylet was removed.  the r-wave measured at 40 millivolts.  the impedance was 580 and the threshold was 1.3 volt.  the numbers were accepted and because of the patient&#8217;s fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  i decided to proceed with a single-chamber pacemaker as a backup system. after that, the lead sleeve was used to actively fixate the lead in the anterior chest with two ethibond sutures in the usual fashion. the lead was attached to the pacemaker in the header.  the pacemaker was single-chamber pacemaker altura 60, serial number 123456.  after that, the pacemaker was put in the pocket.  pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 vicryl and surface as continuous #4-0 vicryl continuous. the pacemaker was programmed as vvi 60, and with history is 10 to 50 beats per minute.  the lead position will be evaluated with chest x-ray. no significant bleeding noticed. conclusion:  successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  no significant bleed."
+"i had the pleasure of seeing mr. abc in neurologic consultation and follow-up on mm/dd/yyyy.  mr. abc reports that he has had several issues in the family.  one of them is that his grandmother passed.  in addition, the family dog fell ill.  this has led to distress.  he reports better controlled pain.  mr. abc reports, otherwise, intermittent adherence to copaxone.  he had in the past been on interferon, but did not tolerate the medication, because of side effects.  his sleep/wake cycle remains very erratic. social history, family history, and past medical history: reviewed.  there are no changes, otherwise. review of systems:  fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder. examination:  the patient is alert and oriented.  extraocular movements are full.  the face is symmetric.  the uvula is midline.  speech has normal prosody.  today there is much less guarding of the left shoulder.  in the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full.  the gait is narrow based and noncircumductive.  rapid alternating movements are slightly off bilaterally.  the gait does not have significant slapping characteristics.  sensory examination is largely unremarkable.  heart, lungs, and abdomen are within normal limits. impression:  mr. abc is doing about the same.  we discussed the issue of adherence to copaxone.  in order to facilitate this, i would like him to take copaxone every other day, but on a regular rhythm.  his wife continues to inject him.  he has not been able to start himself on the injections. greater than 50% of this 40-minute appointment was devoted to counseling."
+"reason for exam:  cva. indications:  cva. this is technically acceptable.  there is some limitation related to body habitus. dimensions:  the interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9. findings:  the left atrium was mildly dilated.  no masses or thrombi were seen.  the left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, ef of 60%.  the right atrium and right ventricle are normal in size. mitral valve showed mitral annular calcification in the posterior aspect of the valve.  the valve itself was structurally normal.  no vegetations seen.  no significant mr. mitral inflow pattern was consistent with diastolic dysfunction grade 1.  the aortic valve showed minimal thickening with good exposure and coaptation.  peak velocity is normal.  no ai. pulmonic and tricuspid valves were both structurally normal. interatrial septum was appeared to be intact in the views obtained.  a bubble study was not performed. no pericardial effusion was seen.  aortic arch was not assessed. conclusions:1.  borderline left ventricular hypertrophy with normal ejection fraction at 60%.2.  mitral annular calcification with structurally normal mitral valve.3.  no intracavitary thrombi is seen.4.  interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained."
+<strong>report:</strong> the electroencephalogram shows background activity at about 9-10 cycle/second bilaterally. little activity in the beta range is noted. waves of 4-7 cycle/second of low amplitude were occasionally noted. abundant movements and technical artifacts are noted throughout this tracing. hyperventilation was not performed. photic stimulation reveals no important changes. <strong>clinical interpretation:</strong> the electroencephalogram is essentially normal.
+"exam:  ct scan of the abdomen and pelvis without and with intravenous contrast. clinical indication:  left lower quadrant abdominal pain. comparison:  none. findings:  ct scan of the abdomen and pelvis was performed without and with intravenous contrast.  total of 100 ml of isovue was administered intravenously.  oral contrast was also administered. the lung bases are clear.  the liver is enlarged and decreased in attenuation.  there are no focal liver masses. there is no intra or extrahepatic ductal dilatation. the gallbladder is slightly distended. the adrenal glands, pancreas, spleen, and left kidney are normal. a 12-mm simple cyst is present in the inferior pole of the right kidney.  there is no hydronephrosis or hydroureter. the appendix is normal. there are multiple diverticula in the rectosigmoid.  there is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  these findings are consistent with diverticulitis.  no pneumoperitoneum is identified.  there is no ascites or focal fluid collection. the aorta is normal in contour and caliber. there is no adenopathy. degenerative changes are present in the lumbar spine. impression:  findings consistent with diverticulitis.  please see report above."
+"referral questions:  mr. abcd was referred for psychological assessment by his primary medical provider, to help clarify his diagnosis, especially with respect to attention deficit hyperactivity disorder, a depression, or a bipolar spectrum disorder.  the information will be used for treatment planning. background information:  mr. abcd is a 33-year-old married man who lives with his wife and three children.  he has been married since 1995 and lost a son to sids over seven years ago.  he served in the army for two years, and did attend some college at uaa.  he still wants to get a degree in engineering.  mr. abcd indicated that he did use thc at the time of his initial intake with me in january 2006, but there are no other substance abuse issues as an adult so far as i am aware.  he has had multiple stressors, including a bankruptcy in 2000, as well as his wife&#8217;s significant health problems.  he also reported having herniated discs incurred in an injury over a year ago.  he has received counseling in the past, and did try both lexapro and wellbutrin, which he stopped taking in october 2005.  he indicated these medications tended to decrease libido and flatten all of his emotions.  he indicated that he thought he might have attention deficit hyperactivity disorder, but that this had not been formally evaluated or treated.  there is no reported bipolar illness in his immediate family, but there is some depression.  a recent stressor involved ocs involvement, apparently because his infant child tested positive for thc.  so far as i am aware, this case is closed at this time.   behavioral observations:  mr. abcd arrived on time for his testing session dressed casually and with good hygiene and grooming.  mood is reported to be generally okay, though with some stress.  affect was bright and appropriate to the situation.  speech was a little pressured, but was of normal content and was at all times coherent and goal directed.  he was a very pleasant and cooperative testing subject, who appeared to give a good effort on the tasks requested of him.  the results appear to provide a useful sample of his current attitudes, opinions, and functional levels in the areas assessed. assessment results:  mr. abcd&#8217;s responses to a brief self-report instrument given to him by dr. starks was suggestive of symptoms that could be consistent with attention deficit hyperactivity disorder.  i therefore had him complete the conners cpt-ii, which showed good performance and no indications of attention problems.  the confidence index associated with adhd was over 58 percent that no clinical attention problems are present.  while a diagnosis of attention deficit hyperactivity disorder should not unequivocally be ruled out based on the results of this test, there is nothing in the cpt-ii measures indicating attention problems, and that diagnosis appears to be unlikely.  the mmpi-2 profile is a technically valid and interpretable one.  the modified welsh code is as follows:  49+86-231/570:  f&#8217;+-/:lk#.  the high f scale may reflect some moodiness, restlessness, dissatisfaction, and changeableness in his typical behavior.  the basic clinical profile is similar to persons who tend to get into trouble for violating social norms and rules.  such persons are more likely to experience conflicts with authority.  they also are prone to impulsivity, self-indulgence, problems with delay of gratification, exercise problematic judgment, and often have low frustration tolerance.  those with similar scores tend to be moody, irritable, extraverted, and often do not trust others very much.  mr. abcd may tend to keep others at a distance, yet feel rather insecure and dependent.  a bipolar diagnosis is a possibility, and an antisocial personality disorder cannot be entirely ruled out either, though i am less confident that that is correct.  the mmpi-2 content scale scores indicate some mild depression and family stressors, and the supplementary scales has a single clinical elevation on addiction admission, which is entirely consistent with his interview data.  posttraumatic stress scales are not elevated at a clear clinical level on the mmpi-2. summary and recommendations:   mr. abcd certainly has multiple stressors in his life, and i suspect that some of his reported attention and concentration difficulties are more related to those problems than to attention deficit hyperactivity disorder.  conners cpt-ii results do not provide support for that diagnosis, and in the absence of other data, i would tend to rule out adhd at this time.  the mmpi-2 profile indicates some problems with impulsivity, family stressors, and mild depressive symptoms.  posttraumatic stress disorder scales do not reach clinical significance.  the profile suggests some impulsivity, restlessness, moodiness, irritability, problems with frustration tolerance, poor decision making, and potential conflicts with authority.  a bipolar spectrum disorder diagnosis is a possibility and i would recommend exploring treatment options to further examine and address this.  an antisocial personality disorder may be present, or traits of antisocial personality may be present, but at this point, i do not see sufficient evidence to warrant that diagnosis."
+"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&#8217;s hematocrit stabilized at 25.  during the patient&#8217;s stay, the patient&#8217;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&#8217;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&#8217;s prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  during the patient&#8217;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&#8217;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."
+"preoperative diagnosis:  alternating hard and soft stools. postoperative diagnosis:sigmoid diverticulosis.sessile polyp of the sigmoid colon.pedunculated polyp of the sigmoid colon. procedure:  total colonoscopy with biopsy and snare polypectomy. prep:  4/4.difficulty:  1/4.premedication and sedation:  fentanyl 100, midazolam 5. indication for procedure:  a 64-year-old male who has developed alternating hard and soft stools.  he has one bowel movement a day. findings:  there is extensive sigmoid diverticulosis, without evidence of inflammation or bleeding.  there was a small, sessile polyp in the sigmoid colon, and a larger pedunculated polyp in the sigmoid colon, both appeared adenomatous. description of procedure:  preoperative counseling, including an explicit discussion of the risk and treatment of perforation was provided.  preoperative physical examination was performed.  informed consent was obtained.  the patient was placed in the left lateral decubitus position.  premedications were given slowly by intravenous push.  rectal examination was performed, which was normal.  the scope was introduced and passed with minimal difficulty to the cecum.  this was verified anatomically and video photographs were taken of the ileocecal valve and appendiceal orifice.  the scope was slowly withdrawn, the mucosa carefully visualized.  it was normal in its entirety until reaching the sigmoid colon.  sigmoid colon had extensive diverticular disease, small-mouth, without inflammation or bleeding.  in addition, there was a small sessile polyp, which was cold biopsied and recovered, and approximately an 8 mm pedunculated polyp.  a snare was placed on the stalk of the polyp and divided with electrocautery.  the polyp was recovered and sent for pathologic examination.  examination of the stalk showed good hemostasis.  the scope was slowly withdrawn and the remainder of the examination was normal. assessment:  diverticular disease.  a diverticular disease handout was given to the patient&#8217;s wife and a high fiber diet was recommended.  in addition, 2 polyps, one of which is assuredly an adenoma.  patient needs a repeat colonoscopy in 3 years."
+"cc: lethargy. hx: this 28y/o rhm was admitted to a local hospital on 7/14/95 for marked lethargy. he had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. on the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. he denied fevers, chills, sweats, cough, cp, sob or diarrhea. upon evaluation locally, he had a temperature of 99.5f and appeared lethargic. he also had anisocoria with left pupil 0.5mm bigger than the right. there was also question of left facial weakness. an mri was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. he was given 10mg of iv decardron,100gm of iv mannitol, intubated and hyperventilated and transferred to uihc. he was admitted to the department of medicine on 7/14/95, and transferred to the department of neurology on 7/17/95, after being extubated. meds on admission: bactrim ds qd, diflucan 100mg qd, acyclovir 400mg bid, xanax, stavudine 40mg bid, rifabutin 300mg qd. pmh: 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) hiv/aids dx 1991. he was initially treated with azt, then ddi. he developed chronic diarrhea and was switched to d4t in 1/95. however, he developed severe neuropathy and this was stopped 4/95. the diarrhea recured. he has acyclovir resistant genital herpes and generalized psoriasis. he most recent cd4 count (within 1 month of admission) was 20. fhx: htn and multiple malignancies of unknown type. shx: homosexual, in monogamous relationship with an hiv infected partner for the past 3 years. exam: 7/14/95 (by internal medicine): bp134/80, hr118, rr16 on vent, 38.2c, intubated. ms: somnolent, but opened eyes to loud voices and would follow most commands. cn: pupils 2.5/3.0 and &quot;equally reactive to light.&quot; mild horizontal nystagmus on rightward gaze. eom were otherwise intact. motor: moved 4 extremities well. sensory/coord/gait/station/reflexes: not done. gen exam: penil ulcerations. exam: 7/17/96 (by neurology): bp144/73, hr59, rr20, 36.0, extubated. ms: alert and mildly lethargic. oriented to name only. thought he was a local hospital and that it was 1/17/1994. did not understand he had a brain lesion. cn: pupils 6/5.5 decreasing to 4/4 on exposure to light. eom were full and smooth. no rapd or light-near dissociation. papilledema (ou). right lower facial weakness and intact facial sensation to pp testing. gag-shrug and corneal responses were intact, bilaterally. tongue midline. motor: grade 5- strength on the right side. sensory: no loss of sensation on pp/vib/prop testing. coord: reduced speed and accuracy on right fnf and right hks movements. station: rue pronator drift. gait: not done. reflexes: 2+/2 throughout. babinski sign present on right and absent on left. gen exam: unremarkable except for the genital lesion noted by internal medicine. course: the outside mri was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. the mass inhomogenously enhanced with gadolinium contrast. the findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. he refused brain biopsy and was started on empiric treatment for toxoplasmosis. this consisted of pyrimethamine 75mg qd and sulfadiazine 2 g bid. he later became dnr and was transferred at his and his partner&#8217;s request back to a local hospital. he never returned for follow-up."
+exam:  bilateral renal ultrasound. clinical indication:  uti. technique:  transverse and longitudinal sonograms of the kidneys were obtained. findings:  the right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  the left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  there is no evidence for hydronephrosis or perinephric fluid collections.  the bladder is of normal size and contour.  the bladder contains approximately 13 ml of urine after recent voiding.  this is a small postvoid residual. impression:  normal renal ultrasound.  small postvoid residual.
+"history of present illness: the patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  at that time, he reports both legs gave away on him and he fell.  he reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  he was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal. he was then well until the 3rd of july 2008 when his legs again gave way on him.  this was not preceded by lightheadedness.  he was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  he started using a walker from that time, prior to that he was able to walk approximately two miles per day.  he again had a fall in august of 2008 after his legs gave way.  again, there was no lightheadedness associated with this.  he was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  he did not, however, return to the pre-july baseline.  in october of 2008, after another fall, he was found to have pneumonia again and shingles.  he is currently in a chronic rehabilitation unit.  he cannot use a walker and uses a wheelchair for everything.  he states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  he is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  he does, however, note that strength in his hands has not been normal since july 2008, but it is clearly getting worse.  he has been aware of some fasciculations in his legs starting in august 2008, these are present both in the lower legs and the thighs.  he does not report any cramps, problems with swallowing or problems with breathing.  he reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  he has had some problems with blood pressure drops, and does feel presyncopal when he stands.  he also reports that he has no feeling in his feet, and that his feet feel like sponges.  this has been present for about nine months.  he has also lost joint position sense in his feet for approximately nine months. past medical history:1.  pneumonia.  he has had recurrent episodes of pneumonia, which started at approximately age 20.  these have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  he is usually treated with antibiotics and then discharged.  there is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.2.  he has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  the patient does not have any history of diabetes and does not report any other medical problems.  he has lost approximately 18 pounds in the past month.3.  he had an appendectomy in the 1940s.4.  he had an ankle resection in 1975. social history:  the patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  he has not smoked for the past 27 years.  he hardly ever uses alcohol.  he is currently retired. family history:  there is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  his aunt has a history of type ii diabetes. current medications:  fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., cymbalta 30 mg p.o. per day, prilosec 20 mg p.o. per day, lortab 10 mg p.o. per day, amoxil 500 mg p.o. per day, vitamin b12 1000 mcg weekly, vitamin d 1000 units per day, metamucil p.r.n., enteric-coated aspirin once a day, colace 200 mg p.o. q.d., senokot three tablets p.o. p.r.n., reglan 10 mg p.o. q.6h., xanax 0.25 mg p.o. q.8h. p.r.n., ambien 5 mg p.o. q.h.s. p.r.n. and dilaudid 2 mg tablets p.o. q.3h. p.r.n., protonix 40 mg per day, and megace 400 mg per day. allergies:  he has no medication or food allergies. review of systems:  please see the health questionnaire and clinical notes from today. general physical examination:vital signs:  bp was 137/60, p was 89, and his weight could not be measured because he was in a wheelchair.  his pain score was 0.appearance:  no acute distress.  he is pleasant and well-groomed.heent:  atraumatic, normocephalic.  no carotid bruits appreciated.lungs:  there were few coarse crackles in both lung bases.cardiovascular:  revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  the pulse was regular and of normal volume.abdomen:  soft with no masses and normal bowel sounds.  there were no carotid bruits.extremities:  no contractures appreciated. neurological exam:mse:  his orientation, language, calculations, 100-7 tests were all normal.  there was atrophy and fasciculations in both the arms and legs.cranial nerves:  cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  his palatal movement was normal and gag reflex was normal.motor:  strength was decreased in all muscle groups as follows:  deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  there was atrophy in both hands and general atrophy of the lower limb muscles.  the feet were both cold and showed dystrophic features.  fasciculations were present mainly in the hands.  there was evidence of dysmetria and past pointing in the left hand.reflexes:  reflexes were 0 in all sites in the arms and legs.  the jaw reflex was 2+.  vibration was severely decreased at the elbow and wrist and was absent in the fingers.  vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  joint position sense was absent in the toes and severely decreased in the fingers.  pin perception was absent in the feet and was decreased to the upper thighs.  pin was decreased or absent in the fingers and decreased above the elbows.  the same distribution of sensory loss was found with monofilament testing.coordination:  coordination was barely normal in the right hand.  rapid alternating movements were decreased in the left hand greater than the right hand.  the patient was unable to stand and therefore gait, romberg&#8217;s test and balance could not be assessed. diagnostic studies:  previous diagnostic studies and patient reports.  there were extensive patient reports, all of which were reviewed.  a previous x-ray study of the lateral chest performed in october 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  an x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  a cta of the neck with and without contrast performed in november 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  the posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  there was no significant stenosis, but there was minor extracranial stenosis noted.  an mri of the brain with and without contrast performed in november 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  there was also no significant sinusitis or mastoiditis.  this was an essentially normal brain mri.  a cbc performed in january 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated mch of 32.4 and the rest of the study was normal.  an electrolyte study performed in january 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  the glucose was 86.  tsh performed in january 2009 was 1.57, which is within the normal range.  vitamin b12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  a myocardial stress study performed in december 2008 showed normal myocardial perfusion with persantine cardiolite spect.  the ecg was non-diagnostic.  there was normal regional wall motion of the left ventricle.  the left ventricular ejection fraction was 68%, which is within the normal range for males.  a ct of the lumbar spine without contrast performed in december 2008 showed a broad-based disc bulge at l1-l2, l2-l3, l3-l4 and l4-l5.  at l5-s1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  there was severe bilateral neural foraminal stenosis at l5-s1 and moderate neural foraminal stenosis at l1-l4.  an echocardiogram was performed in november 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation. diagnostic impression:  the patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  he is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  his proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  according to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since july 2008.  as indicated below, further diagnostic studies including a detailed nerve conduction and emg test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  there was no involvement of the tongue on emg.  the laboratory testing as indicated below failed to show a specific cause for the neuropathy.  we are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the mayo clinic.  this type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as sle, sjogren&#8217;s, rheumatoid arthritis, and mixed connective tissue disease.  in addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  the patient did not receive any of these.  it may also be seen as part of a paraneoplastic syndrome.  although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  we have requested that he obtain a ct of his chest, abdomen and pelvis while he is in acute rehabilitation.  the verbal reports of these possibly did not show any evidence of a cancer.  we did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  the patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  this showed evidence of severe axonal loss.  there was no evidence of a vasculitis.  the vessels did show some mild intimal changes that would be consistent with atherosclerosis.  there were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  the muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  again, there was no evidence of inflammation or vasculitis.  evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  specifically, there is no history of hiv exposure.  we would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  at this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  i have discussed these issues at length with the patient and with his son.  we also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  i think this is unlikely given the short history and the rapid progression of the disorder. there is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as charcot-marie-tooth disease type 2.  however, since i have only seen the patient on one occasion and do not know what his previous examination showed two years ago, i cannot be certain that there may not have been the presence of a neuropathy preceding this. plan:1.  nerve conduction and emg will be performed today.  the results were indicated above.2.  the following laboratory studies were requested including electrolytes, cbc, thyroid function tests, b12, ana, c-reactive protein, complement, cryoglobulins, double-stranded dna antibodies, folate level, hemoglobin a1c, immunofixation electrophoresis, p-anca, c-anca, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the mayo clinic, b12.  these studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  the b12 was greater than 2000.  the immunoelectrophoresis, ana, double-stranded dna, anca, hemoglobin a1c, folate, cryoglobulins, complement, c-reactive protein were all normal or negative.  the b12 level was greater than 2000.  liver function tests were normal.  the glucose was 90.  esr was 10.  hemoglobin a1c was 5.5.3.  a left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.4.  ct of chest, abdomen and pelvis.5.  whole body gallium scan for evidence of an underlying neoplasm.6.  the patient will go to the rehabilitation facility for acute rehabilitation and training.7.  we have not made any changes to his medication.  he does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.8.  followup will be as determined by the family."
+"reason for visit:  the patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  he is accompanied by his wife and daughter. history of present illness:  i first saw him nearly a year ago on december 20, 2007.  at that time, he had had a traumatic deterioration over the course of approximately eight months.  this included severe cognitive impairment, gait impairment, and incontinence.  he had actually been evaluated at hospital with csf drainage via a temporary spinal catheter, but there was no response that was noted.  when i saw him, there were findings consistent with cervical stenosis and i ordered an mri scan of the cervical spine.  i subsequently referred him to dr. x, who performed a cervical laminectomy and instrumented fusion on july 16, 2008.  according to his notes this went well. according to the family, there has not been any improvement. with regard to the gait and balance, they actually think that he is worse now than he was a year ago.  he is virtually unable to walk at all.  he needs both a walker and support from an assistant to be able to stand or walk.  therefore, he is always in the wheelchair. he is completely incontinent.  he never indicates his need to the go to the bathroom.  on the other hand when asked, he will indicate that he needs to go.  he wears a depends undergarment all the time. he has no headaches. his thinking and memory are worse.  for the most part, he is apathetic.  he does not talk very much.  he lives in a skilled nursing facility in the alzheimer&#8217;s section.  he does have some daytime activities.  he takes a nap once a day.  he does not read very much.  on the other hand, he did recently exercise the right to vote in the presidential election.  he needs full assistance at the nursing home. medications:  from the list by the nursing home are aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (celexa) 40 mg daily, colace 100 mg twice a day, finasteride (proscar) 5 mg once a day, flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (prilosec) 20 mg once a day, senna 8.6 mg twice a day, tylenol 650 mg as needed, and promethazine 25 mg as needed. physical exam:  on examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  he is well developed, well nourished, and kempt. vital signs:  temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71. head:  the head is normocephalic and atraumatic. mental status:  assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  the mini-mental state exam score was 14/30.  he was not at all oriented.  he did know we were at sinai hospital on the second floor.  he could spell &#8216;world&#8217; forward, but was mute when asked to spell backwards.  he was mute when asked to recall 3/3 objects for delayed recall.  he could not copy a diagram of intersecting pentagons.  for comparison, the mini-mental state exam score last december was 20/30 when attention was tested by having him spell &#8216;world&#8217; backwards and 28/30 when tested with serial 7 subtractions.  additionally, there are times when he stutters or stammers.  i do not see any paraphasic errors.  there is some evidence of ideomotor apraxia.  he is also stimulus bound.  there is a tendency to mimic. cranial nerve exam:  there is no upgaze that i can elicit today.  the horizontal gaze and down gaze are intact.  this is a change from a year ago.  the muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement. motor exam:  normal bulk and strength.  the tone is characterized by paratonia.  there is no atrophy, fasciculations, drift, or tremor. sensory exam:  intact to light touch. cerebellar exam:  intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands. gait:  severely impaired.  when in the wheelchair, he leans to one side.  he cannot getup on his own.  he needs assistance.  once up, he can bear weight, but cannot maintain his balance.  this would amount to a tinetti score of zero. review of x-rays:  i personally reviewed the ct scan of the brain from november 1, 2008 and compared it to the mri scan from a year ago.  the ventricles appear larger to me now in comparison to a year ago.  the frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  the 3rd ventricular span is about 15 mm.  there is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  the scan from a year ago showed that there was a patent sylvian aqueduct. assessment:  the patient has had worsening of his gait, his dementia, and his incontinence.  the new finding for me today is the limited upgaze.  this would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles. problems/diagnoses:1.  question of idiopathic normal pressure hydrocephalus (331.5).2.  possible supranuclear palsy.3.  severe gait impairment.4.  urinary urgency and incontinence.5.  dementia. plan:  i had a long talk with him and his family.  even though he has already had a trial of csf drainage via spinal catheter at hospital over a year ago, i offered this test to them again.  i do so on the basis that there is further enlargement of the ventricles on the scan.  his family and i discussed the facts that it is not likely to be only hydrocephalus.  instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  i have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  i gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  i specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection."
+"indication for study:  chest pains, cad, and cardiomyopathy. medications:  humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam. baseline ekg:  sinus rhythm at 71 beats per minute, left anterior fascicular block, lvbb. persantine results:  heart rate increased from 70 to 72.  blood pressure decreased from 160/84 to 130/78.  the patient felt slightly dizziness, but there was no chest pain or ekg changes. nuclear protocol:  same day rest/stress protocol was utilized with 12 mci for the rest dose and 33 mci for the stress test.  53 mg of persantine were used, reversed with 125 mg of aminophylline. nuclear results:1.  nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  the resting images are normal.  the post persantine images show mildly decreased uptake in the septum.  the sum score is 0.2.  the gated spect shows enlarged heart with a preserved ef of 52%. impression:1.  mild septal ischemia.  likely due to the left bundle-branch block.2.  mild cardiomyopathy, ef of 52%.3.  mild hypertension at 160/84.4.  left bundle-branch block."
+"chief complaint:  this 5-year-old male presents to children&#8217;s hospital emergency department by the mother with &quot;have asthma.&quot;  mother states he has been wheezing and coughing.  they saw their primary medical doctor.  he was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  they told to go to the er if he got worse.  he has had some vomiting and some abdominal pain.  his peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day. past medical history:  asthma with his last admission in 07/2007.  also inclusive of frequent pneumonia by report. immunizations:  up-to-date. allergies:  denied. medications:  advair, nasonex, xopenex, zicam, zithromax, prednisone, and albuterol. past surgical history:  denied. social history:  lives at home, here in the ed with the mother and there is no smoking in the home. family history:  no noted exposures. review of systems:  documented on the template.  systems reviewed on the template. physical examination:vital signs:  temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  oxygen saturation low at 91% on room air. general:  this is a well-developed male who is cooperative, alert, active with oxygen by facemask. heent:  head is atraumatic and normocephalic.  pupils are equal, round, and reactive to light.  extraocular motions are intact and conjugate.  clear tms, nose, and oropharynx. neck:  supple.  full painless nontender range of motion. chest:  tight wheezing and retractions heard bilaterally. heart:  regular without rubs or murmurs. abdomen:  soft, nontender.  no masses.  no hepatosplenomegaly. genitalia:  male genitalia is present on a visual examination. skin:  no significant bruising, lesions or rash. extremities:  moves all extremities without difficulty, nontender.  no deformity. neurologic:  symmetric face, cooperative, and age appropriate. medical decision making:  the differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  he is evaluated in the emergency department with continuous high-dose albuterol, decadron by mouth, pulse oximetry, and close observation.  chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  she is further treated in the emergency department with continued breathing treatments.  at 0048 hours, he has continued tight wheezes with saturations 99%, but ed sats are 92% with coughing spells.  based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma."
+"chief complaint:  chest pain. history of present illness:  the patient is a 40-year-old white male who presents with a chief complaint of &quot;chest pain&quot;. the patient is diabetic and has a prior history of coronary artery disease.  the patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  the severity of the pain has progressively increased.  he describes the pain as a sharp and heavy pain which radiates to his neck &#038; left arm.  he ranks the pain a 7 on a scale of 1-10.  he admits some shortness of breath &#038; diaphoresis.  he states that he has had nausea &#038; 3 episodes of vomiting tonight.  he denies any fever or chills.  he admits prior episodes of similar pain prior to his ptca in 1995.  he states the pain is somewhat worse with walking and seems to be relieved with rest.  there is no change in pain with positioning.  he states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  the patient ranks his present pain a 4 on a scale of 1-10.  the most recent episode of pain has lasted one-hour. the patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed. review of systems:  all other systems reviewed &#038; are negative. past medical history:  diabetes mellitus type ii, hypertension, coronary artery disease, atrial fibrillation, status post ptca in 1995 by dr. abc. social history:  denies alcohol or drugs.  smokes 2 packs of cigarettes per day.  works as a banker. family history:  positive for coronary artery disease (father &#038; brother). medications:  aspirin 81 milligrams qday.  humulin n. insulin 50 units in a.m.  hctz 50 mg qday.  nitroglycerin 1/150 sublingually prn chest pain. allergies:  penicillin. physical exam:  the patient is a 40-year-old white male.general:  the patient is moderately obese but he is otherwise well developed &#038; well nourished.  he appears in moderate discomfort but there is no evidence of distress.  he is alert, and oriented to person place and circumstance.  there is no evidence of respiratory distress.  the patient ambulates    without gait abnormality or difficulty.heent:  normocephalic/atraumatic head.  pupils are 2.5 mm, equal round and react to light bilaterally.  extra-ocular muscles are intact bilaterally.  external auditory canals are clear bilaterally.  tympanic membranes are clear and intact bilaterally.neck:  no jvd.  neck is supple.  there is free range of motion &#038; no tenderness, thyromegaly or lymphadenopathy noted.pharynx:  clear, no erythema, exudates or tonsillar enlargement.chest:  no chest wall tenderness to palpation.  lungs:  clear to auscultation bilaterally.  heart:  irregularly-irregular rate and rhythm no murmurs gallops or rubs.  normal pmiabdomen:  soft, non-distended.  no tenderness noted.  no cvat.skin:  warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.extremities:  no gross visible deformity, free range of motion.  no edema or cyanosis.  no calf/ thigh tenderness or swelling. course in emergency department:  the patient&#8217;s chest pain improved after the sublingual nitroglycerine and completely resolved with the nitroglycerin drip at 30 ug/minute.  he tolerated the tpa well.  he was transferred to the ccu in a stable condition procedures:10:40 pm dr. abc (cardiologist) apprised.  he agrees with t pa per 90 minute protocol &#038; iv nitroglycerin drip.  he is to come see patient in the emergency department.10:45 pm risks &#038; benefits of tpa discussed with patient &#038; his family.  they agree with administration of tpa and are willing to accept the risks.10:50 pm tpa started.11:20 pm dr. abc present in emergency department assisting with patient care. diagnostic studies:cbc:  wbc 14.2, hematocrit 33.5, platelets 316chem 7:  na 142, potassium 4.5, chloride 102, co2 22.6, bun 15, creatinine 1.2, glucose 186serum troponin i:  2.5chest x-ray:  lung fields clear.  no cardiomegaly or other acute findingsekg:  atrial fibrillation with ventricular rate of 65.  acute inferior ischemic changes noted i.e.  st elevation iii &#038; avf (refer to ekg multimedia).cardiac monitor:  sinus rhythm-atrial of fibrillation rate 60s-70s. treatment:heparin lock x. 2.nasal cannula oxygen 3 liters/minute.aspirin 5 grains chew &#038; swallow.nitroglycerin drip at 30 micrograms/minute.cardiac monitor.tpa 90 minute protocol.heparin iv 5000 unit bolus followed by 1000 units/hour. impression:  acute inferior myocardial infarction. plan:  patient admitted to coronary care unit under the care of dr. abc."
+"procedure: esophagogastroduodenoscopy with biopsy and snare polypectomy. indication for the procedure: iron-deficiency anemia. medications: mac. the risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration. procedure: after informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. the duodenal mucosa was completely normal. the pylorus was normal. in the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. multiple biopsies were obtained. there also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. there was mild ulceration on the tip of this polyp. it was decided to remove the polyp via snare polypectomy. retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. the z-line was identified and was unremarkable. the esophageal mucosa was normal. findings:1. hiatal hernia.2. diffuse nodular and atrophic appearing gastritis, biopsies taken.3. a 1.5-cm polyp with ulceration along the greater curvature, removed. recommendations:1. follow up biopsies.2. continue ppi.3. hold lovenox for 5 days.4. place scds."
+"preoperative diagnosis:  iron deficiency anemia. postoperative diagnosis:  diverticulosis. procedure:  colonoscopy. medications:  mac. procedure:  the olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  the mucosa was normal throughout the colon.  no polyps or other lesions were identified, and no blood was noted.  some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  a retroflex view of the anorectal junction showed no hemorrhoids.  the patient tolerated the procedure well and was sent to the recovery room. final diagnoses:1.  diverticulosis in the sigmoid.2.  otherwise normal colonoscopy to the cecum. recommendations:1.  follow up with dr. x as needed.2.  screening colonoscopy in 2 years.3.  additional evaluation for other causes of anemia may be appropriate."
+"history of present illness:  this is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  his most recent bun and creatinine on 04/04/06 are 40/2.0, which is stable.  he denies any chest pain or tightness in his chest.  he denies any shortness of breath, nausea, or vomiting.  he denies any change to his appetite.  he denies any fevers, chills, dysuria, or hematuria.  he does report his blood pressure being checked at the senior center and reporting that it is improved.  the patient has stage iii chronic kidney disease.  past medical history:   no recent hospitalizations.   current medications:  1.  pravachol 20 mg q.d.  he is supposed to be taking b.i.d. but has nightmares with increased dosing.2.  metoprolol 50 mg one-half tablet b.i.d.3.  norvasc 10 mg a day.4.  avodart one tablet q.d.5.  aspirin 81 mg a day.6.  vitamin c one a day.7.  vitamin e one a day. physical examination:  an alert white male in no acute distress.  vital signs:  weight:  174 pounds, which is unchanged.  blood pressure:  right arm sitting 122/62.  pulse:  80.  heent:  normocephalic and atraumatic.  sclerae are anicteric.  pupils are equal and reactive.  external inspection of the ears and nose are unremarkable.  throat is without erythema.  neck:  supple.  no thyromegaly.  lungs:  clear.  no dullness or rales.  heart:  s4.  no murmur:  abdomen:  obese and nontender with normoactive bowel sounds.  extremities:  without edema.  laboratory data:   urinalysis by myself in the office:  a ph of 6.0, negative blood, negative leukocyte esterase,  and spot protein/creatinine ratio 300 mg/gram, which is abnormal.  on 04/04/06:  sodium 137, potassium 3.4, chloride 98, co2 27, bun 40, creatinine 2.0, glucose 99, calcium 8.8, phosphorus 3.4, albumin 3.8, triglycerides 184, cholesterol 180, ldl 98, hdl 45, pth 98, wbc 6.2, hemoglobin 12.9, and hematocrit 38. assessment and plan:1.  chronic kidney disease, stage iii secondary to nephrosclerosis with nonfunctioning right kidney.2.  hypertension, improved.3.  history of orthostatic hypotension.4.  peripheral vascular disease, status post aaa graft.5.  history of right common iliac aneurysm.  6.  bph.7.  coronary artery disease, status post cabg.  no recent chest pain.8.  mild secondary hyperparathyroidism.  9.  hyperlipidemia with increased ldl.10.  history of hypokalemia related to hctz. discussion:  the patient&#8217;s bun and creatinine are stable.  i recommended for him to eat foods higher in potassium.   recommendations:  in summary:1.  continue present medications.2.  a high-potassium diet.3.  follow up in four months with labs prior to his next visit:  cmp, phosphorus, cbc, pth, and iron stores."
+"procedure:  gastroscopy. preoperative diagnosis:  dysphagia and globus. postoperative diagnosis:  normal. medications:  mac. description of procedure:  the olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  the preparation was good and all surfaces were well seen.  the hypopharynx was normal with no evidence of inflammation.  the esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  the ge junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or barrett&#8217;s.  below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  the gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  the scope was withdrawn and the patient was sent to recovery room.  she tolerated the procedure well. final diagnoses:1.  normal post-gastric bypass anatomy.2.  no evidence of inflammation or narrowing to explain her symptoms."
+"preoperative diagnosis:  prior history of neoplastic polyps. postoperative diagnosis:  small rectal polyps/removed and fulgurated. premedications:  prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  i asked the nurse to give her 25 mg of demerol iv. following the iv demerol, she had a nausea reaction.  she was then given 25 mg of phenergan iv.  following this, her headache and nausea completely resolved.  she was then given a total of 7.5 mg of versed with adequate sedation.  rectal exam revealed no external lesions.  digital exam revealed no mass. reported procedure:  the p160 colonoscope was used.  the scope was placed in the rectal ampulla and advanced to the cecum.  navigation through the sigmoid colon was difficult.  beginning at 30 cm was a very tight bend.  with gentle maneuvering, the scope passed through and then entered the cecum.  the cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  the sigmoid colon was likewise normal.  there were five very small (punctate) polyps in the rectum.  one was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  there was no specimen because the polyps were so small.  the scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated. endoscopic impression:1.  five small polyps as described, all fulgurated.2.  otherwise unremarkable colonoscopy."
+"history of present illness:  this 66-year-old white male was seen in my office on month dd, yyyy.  patient was recently discharged from doctors hospital at parkway after he was treated for pneumonia.  patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  his exercise tolerance is about two to three yards for shortness of breath.  the patient stopped taking coumadin for reasons not very clear to him.  he was documented to have recent atrial fibrillation.  patient has longstanding history of ischemic heart disease, end-stage lv systolic dysfunction, and is status post icd implantation.  fasting blood sugar this morning is 130. physical examination:  vital signs:  blood pressure is 120/60.  respirations 18 per minute.  heart rate 75-85 beats per minute, irregular.  weight 207 pounds.heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good. neck:  supple.  jvp is flat.  carotid upstroke is good. lungs:  severe inspiratory and expiratory wheezing heard throughout the lung fields.  fine crepitations heard at the base of the lungs on both sides. cardiovascular:  pmi felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. first and second heart sounds are normal in character.  there is a ii/vi systolic murmur best heard at the apex.abdomen:  soft.  there is no hepatosplenomegaly.extremities:  patient has 1+ pedal edema. medications:  1.  ambien 10 mg at bedtime p.r.n.2.  coumadin 7.5 mg daily.3.  diovan 320 mg daily.4.  lantus insulin 50 units in the morning.5.  lasix 80 mg daily.6.  novolin r p.r.n.7.  toprol xl 100 mg daily.8.  flovent 100 mcg twice a day. diagnoses:1.  atherosclerotic coronary vascular disease with old myocardial infarction.2.  moderate to severe lv systolic dysfunction.3.  diabetes mellitus.4.  diabetic nephropathy and renal failure.5.  status post icd implantation.6.  new onset of atrial fibrillation.7.  chronic coumadin therapy. plan:1.  continue present therapy.2.  patient will be seen again in my office in four weeks."
+"reason for consultation:  cardiac evaluation. history:  this is a 42-year old caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  patient used to take medicine for hyperlipidemia and then that was stopped.  he used to live in canada and he moved to houston four months ago.  he started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  it lasts around 10-15 minutes at times.  it is 5/10 in quality.  it is not associated with shortness of breath, nausea, vomiting, or sweating.  it is not also associated with food.  he denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  no palpitations, syncope or presyncope.  he said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  no fever, chills, cough, hemoptysis, hematemesis or hematochezia.  his ekg shows normal sinus rhythm, normal ekg. past medical history:  unremarkable, except for hyperlipidemia. social history:  he said he quit smoking 20 years ago and does not drink alcohol. family history:  positive for high blood pressure and heart disease.  his father died in his 50s with an acute myocardial infarction. medication:  ranitidine 300 mg daily, flonase 50 mcg nasal spray as needed, allegra 100 mg daily, advair 500/50 bid. allergies:  no known allergies. review of systems:  as mentioned above examination:  this is a 42-year old male awake, alert, and oriented x3 in no acute distress.wt:  238    bp:  144/82        hr:  69heent:  normocephalic and atraumatic.neck:  supple, no jugular venous distension.lungs:  good breath sounds bilaterally.heart:  regular rate and rhythm, s1 and s2, no murmurs, rubs, or gallops.abdomen:  soft, no organomegalies, bowel sounds positive.extremities:  no clubbing, edema, or cyanosis. impression:1.  right-sided chest pain, rule out coronary artery disease, rule out c-spine radiculopathy, rule out gallbladder disease.2.  borderline elevated high blood pressure.3.  history of hyperlipidemia.4.  obesity. plan:  will schedule patient for heart catheterization.  will see him after the above is completed."
+"<strong>reason for consult: </strong>substance abuse. <strong>history of present illness: </strong>the patient is a 42-year-old white male with a history of seizures who was brought to the er in abcd by his sister following cocaine and nitrous oxide use. the patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago. the patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over. the patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago. the patient says he was depressed and agitated. he says he used cocaine by snorting and nitrous oxide but denies other drug usage. he says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital. the patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure. the patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. the patient is a&amp;o x3. <strong>past psychiatric history:</strong> substance abuse as per hpi. the patient went to a well sober for 15 months. <strong>past medical history:</strong> seizures. <strong>past surgical history:</strong> shoulder injury. <strong>social history:</strong> the patient lives alone in an apartment uses prior to sobriety 15 months ago. he was a binge drinker, although unable to provide detail about frequency of binges. the patient does not work since brother became ill 3 months ago when he quit his job to care for him. <strong>family history:</strong> none reported. <strong>medications outpatient:</strong> seroquel 100 mg p.o. daily for insomnia. <strong>medications inpatient:</strong> 1. gabapentin 300 mg q.8h. 2. seroquel 100 mg p.o. q.h.s. 3. seroquel 25 mg p.o. q.8h. p.r.n. 4. phenergan 12.5 mg iv q.4h. p.r.n. 5. acetaminophen 650 mg q.4h. p.r.n. 6. esomeprazole 40 mg p.o. daily. <strong>mental status examination: </strong>the patient is a 42-year-old male who appears stated age, dressed in a hospital gown. the patient shows psychomotor agitation and is somewhat irritable. the patient makes fair eye contact and is cooperative. he had answers my questions with &#8220;i do not know.&#8221; mood &#8220;depressed&#8221; and &#8220;agitated.&#8221; affect is irritable. thought process logical and goal directed with thought content. he denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. insight and judgment are both fair. the patient seems to understand why he is in the hospital and patient says he will return to alcoholics anonymous and will try to stay sober in all substances following discharge. the patient is a&amp;o x3. <strong>assessment:</strong> axis i: substance withdrawal, substance abuse, and substance dependence. axis ii: deferred. axis iii: history of seizures. axis iv: lives alone and unemployed. axis v: 55. <strong>impression:</strong> the patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety. the patient is experiencing mild symptoms of cocaine withdrawal. <strong>recommendations:</strong> 1. gabapentin 300 mg q.8h. for agitation and history of seizures. 2. reassess this afternoon for reduction in agitation and withdrawal seizures. thank you for the consult. please call with further questions."
+"reason for consultation:  i was asked by dr. x to see the patient in regard to his likely recurrent brain tumor. history of present illness:  the patient was admitted for symptoms that sounded like postictal state.  he was initially taken to hospital.  ct showed edema and slight midline shift, and therefore he was transferred here.  he has been seen by hospitalists service.  he has not had a recurrent seizure.  electroencephalogram shows slowing.  mri of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.  there is inhomogeneous uptake consistent with potential necrosis.  he also has had a spect image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm.  the patient was diagnosed with a brain tumor in 1999.  all details are still not available to us.  he underwent a biopsy by dr. y. one of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at clinic.  that is not available on the chart as i dictate. after discussion of treatment issues with radiation therapist and dr. z (medical oncologist), the decision was made to treat him primarily with radiation alone.  he tolerated that reasonably well.  his wife says it&#8217;s been several years since he had a scan.  his behavior had not been changed, until it changed as noted earlier in this summary. past medical history:  he has had a lumbar fusion.  i believe he&#8217;s had heart disease.  mental status changes are either due to the tumor or other psychiatric problems. social history:  he is living with his wife, next door to one of his children.  he has been disabled since 2001, due to the back problems. review of systems:  no headaches or vision issues.  ongoing heart problems, without complaints.  no weakness, numbness or tingling, except that related to his chronic neck pain.  no history of endocrine problems.  he has nocturia and urinary frequency. physical examination:  blood pressure 146/91, pulse 76.  normal conjunctivae.  ears, nose, throat normal.  neck is supple.  chest clear.  heart tones normal.  abdomen soft.  positive bowel sounds.  no hepatosplenomegaly.  no adenopathy in the neck, supraclavicular or axillary regions.  neurologically alert.  cranial nerves are intact.  strength is 5/5 throughout. laboratory work:  white blood count 10.4, hemoglobin 16, platelets not noted.  sodium 137, calcium 9.1. impression and plan:  likely recurrent low-grade tumor, possibly evolved to a higher grade, given the mri and spect findings.  dr. x&#8217;s note suggests discussing the situation in the tumor board on wednesday.  he is stable enough.  the pause in his care would not jeopardize his current status.  it would be helpful to get old films and pathology from abbott northwestern.  however, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis.  optimizing his treatment would probably be helped by knowing his current grade of tumor."
+"preoperative diagnosis:  acute left subdural hematoma. postoperative diagnosis:  acute left subdural hematoma. procedure:  left frontal temporal craniotomy for evacuation of acute subdural hematoma. description of procedure:  this is a 76-year-old man who has a history of acute leukemia.  he is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  he presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  his ct imaging reveals an acute left subdural hematoma, which is hemispheric. the patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  he had previously been intubated and taken to the intensive care unit and now is brought for emergency craniotomy.  the images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  he was fixed in a three-point headrest.  his scalp was shaved and prepared with betadine, iodine and alcohol.  we made a small curved incision over the temporal, parietal, frontal region.  the scalp was reflected.  a single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  after completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  the brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  we investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  after we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  we placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  the scalp was reapproximated, and the patient was awakened and taken to the ct scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the intensive care unit for further management. i was present for the entire procedure and supervised this.  i confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain."
+"title of procedure:  coronary artery bypass grafting times three utilizing the left internal mammary artery, left anterior descending and reversed autogenous saphenous vein graft to the posterior descending branch of the right coronary artery and obtuse marginal coronary artery, total cardiopulmonary bypass, cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection. description of procedure:  the patient was brought to the operating room and placed in the supine position.  adequate general endotracheal anesthesia was induced.  appropriate monitoring devices were placed.  the chest, abdomen and legs were prepped and draped in the sterile fashion.  the right greater saphenous vein was harvested and prepared by ligating all branches with 4-0 surgilon and flushed with heparinized blood.  hemostasis was achieved in the legs and closed with running 2-0 dexon in the subcutaneous tissue and running 3-0 dexon subcuticular in the skin.  median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  the pericardium was opened.  the pericardial cradle was created.  the patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted.  a retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 prolene suture in the right atrial wall into the coronary sinus and tied to a rumel tourniquet.  an antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 prolene.  the ascending aorta was crossclamped.  cold blood potassium cardioplegia was given to the ascending aorta followed by sumping through the ascending aorta followed by cold retrograde potassium cardioplegia.  the obtuse marginal coronary artery was identified and opened and end-to-side anastomosis was performed to the reversed autogenous saphenous vein with running 7-0 prolene suture and the vein was cut to length.  cold antegrade and retrograde cardioplegia were given and the posterior descending branch of the right coronary artery was identified and opened.  end-to-side anastomosis was performed with a running 7-0 prolene suture and the vein was cut to length.  cold antegrade and retrograde potassium cardioplegia were given.  the mammary artery was clipped distally, divided and spatulated for anastomosis.  the anterior descending was identified and opened.  end-to-side anastomosis was performed through the left internal mammary artery with running 8-0 prolene suture.  the mammary pedicle was sutured to the heart with interrupted 5-0 prolene suture.  a warm antegrade and retrograde cardioplegia were given.  the aortic crossclamp was removed.  the partial occlusion clamp was placed.  aortotomies were made.  the veins were cut to fit these and sutured in place with running 5-0 prolene suture.  a partial occlusion clamp was removed.  all anastomoses were inspected and noted to be patent and dry.  ventricular and atrial pacing wires were placed.  the patient was fully warmed and weaned from cardiopulmonary bypass.  the patient was decannulated in the routine fashion and protamine was given.  good hemostasis was noted.  a single mediastinal and left pleural chest tube were placed.  the sternum was closed with interrupted wire, linea alba with running 0 prolene, the sternal fascia was closed with running 0 prolene, the subcutaneous tissue with running 2-0 dexon and the skin with running 3-0 dexon subcuticular stitch.  the patient tolerated the procedure well."
+"reason for consultation:  neurologic consultation was requested by dr. x to evaluate her seizure medication and lethargy. history of present illness:  the patient is well known to me.  she has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  she also has a history of factor v leiden deficiency.  she was last seen at neurology clinic on 11/16/2007.  at that time, instructions were given to mom to maximize her trileptal dose if seizures continue.  she did well on 2 ml twice a day without any sedation.  this past friday, she had a 25-minute seizure reportedly.  this consisted of eye deviation, unresponsiveness, and posturing.  diastat was used and which mom perceived was effective.  her trileptal dose was increased to 3 ml b.i.d. yesterday. according to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  she appeared to be stable until this past monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  according to mom, she had stopped vomiting since her hospitalization.  reportedly, she was given a medication in the emergency room.  she still is lethargic, will not wake up spontaneously.  when she does awaken however, she is appropriate, and interacts with them.  she is able to eat well; however her overall p.o. intake has been diminished.  she has also been less feisty as her usual sounds.  she has been seizure free since her admission. laboratory data:  pertinent labs obtained here showed the following:  crp is less than 0.3, cmp normal, and cbc within normal limits.  csf cultures so far is negative.  dr. limon&#8217;s note refers to a csf, white blood cell count of 2, 1 rbc, glucose of 55, and protein of 64.  there are no imaging studies in the computer.  i believe that this may have been done at kaweah delta hospital and reviewed by dr. x, who indicated that there was no evidence of shunt malfunction or infection. current medications:  trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin. physical examination:general:  the patient was asleep, but easily aroused.  there was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  she eventually started crying and became agitated.  she made attempts to sit by bending her neck forward.  fully awake, she sucks her bottle eagerly.heent:  she was obviously visually impaired.  pupils were 3 mm, sluggishly reactive to light.extremities:  bilateral lower extremity spasticity was noted.  there was increased flexor tone in the right upper extremity.  iv was noted on the left hand. assessment:  seizure breakthrough due to intercurrent febrile illness.  her lethargy could be secondary to a viral illness with some component of medication effect since her trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded. i concur with dr. x&#8217;s recommendations.  i do not recommend any changes in trileptal for now.  i will be available while she remains hospitalized."
+"procedures:1.  esophagogastroduodenoscopy.2.  colonoscopy with polypectomy. preoperative diagnoses:1.  history of esophageal cancer.2.  history of colonic polyps. postoperative findings:1.  intact surgical intervention for a history of esophageal cancer.2.  melanosis coli.3.  transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy. medications:  fentanyl 250 mcg and 9 mg of versed. indications:  the patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at t2n0m0. he also has a history of adenomatous polyps and presents for surveillance of this process. informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction. esophagogastroduodenoscopy:  the patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  the olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum. findings:1.  esophagus:  anatomy consistent with esophagectomy with colonic transposition.2.  stomach:  revealed colonic transposition with normal mucosa.3.  duodenum:  normal. impression:  intact surgical intervention with esophagectomy colonic transposition. colonoscopy:  the patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  circumferential visualization the colonic mucosa revealed the following:1.  cecum revealed melanosis coli.2.  ascending, melanosis coli.3.  transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.4.  descending, melanosis coli.5.  sigmoid, melanosis coli.6.  rectum, melanosis coli. impression:  diffuse melanosis coli with incidental finding of transverse colon polyps. recommendation:  follow-up histology.  continue fiber with avoidance of stimulant laxatives."
+"procedure:  a 21-channel digital electroencephalogram was performed on a patient in the awake state.  per the technician&#8217;s notes, the patient is taking depakene. the recording consists of symmetric 9 hz alpha activity.  throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  the episodes last from approximately1 to 7 seconds.  the episodes are exacerbated by hyperventilation. impression:  abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  this activity could represent true petit mal epilepsy.  clinical correlation is suggested."
+"preoperative diagnosis:  screening.  postoperative diagnosis:  tiny polyps. procedure performed:   colonoscopy. procedure:   the procedure, indications, and risks were explained to the patient, who understood and agreed.  he was sedated with versed 3 mg, demerol 25 mg during the examination.   a digital rectal exam was performed and the pentax video colonoscope was advanced over the examiner&#8217;s finger into the rectum.  it was passed to the level of the cecum.  the ileocecal valve was identified, as was the appendiceal orifice.   slowly withdrawal through the colon revealed a small polyp in the transverse colon.  this was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  in addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  this was also removed using the cold biopsy forceps.  further detail failed to reveal any other lesions with the exception of small hemorrhoids.   impression:   tiny polyps.   plan:   if adenomatous, repeat exam in five years.  otherwise, repeat exam in 10 years."
+"diagnosis at admission:  chronic obstructive pulmonary disease (copd) exacerbation and acute bronchitis. diagnoses at discharge1.  chronic obstructive pulmonary disease exacerbation and acute bronchitis.2.  congestive heart failure.3.  atherosclerotic cardiovascular disease.4.  mild senile-type dementia.5.  hypothyroidism.6.  chronic oxygen dependent.7.  do not resuscitate/do not intubate. hospital course:  the patient was admitted from the office by dr. x.  she was placed on the usual medications that included synthroid 0.05 mg a day, enalapril 5 mg a day, imdur 30 mg a day, lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and atrovent nebulizers q.4 h., potassium chloride 10 meq 2 tablets per day, lasix 40 mg a day, humibid l.a.  600 mg b.i.d.  she was placed on oral levaquin after a load of 500 mg and 250 mg a day.  she was given oxygen, encouraged to eat, and suctioned as needed. laboratory data included a urinalysis that had 0-2 wbcs per high power field and urine culture was negative, blood cultures x2 were negative, tsh was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, co2 34, glucose 105, bun 17, creatinine 0.9, and calcium 9.1.  digoxin was 1.3.  white blood cell count was 6100 with a normal differential, h&#038;h 37.4/12.1, platelets 335,000.  chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  there is a question if there is mild fluid overload. the patient improved with the above regimen.  by discharge, her lungs fell back to her baseline.  she had no significant shortness of breath.  her o2 saturations were stable.  her vital signs were stable. she is discharged home to follow up with me in a week and a half. her daughter has been spoken to by phone and she will notify me if she worsens or has problems. prognosis:  guarded."
+"cc: found down. hx: 54y/o rhf went to bed at 10 pm at her boyfriend&#8217;s home on 1/16/96. she was found lethargic by her son the next morning. three other individuals in the house were lethargic and complained of ha that same morning. her last memory was talking to her granddaughter at 5:00pm on 1/16/96. she next remembered riding in the ambulance from a hospital. initial carboxyhemoglobin level was 24% (normal &lt; 1.5%) and abg 7.41/30/370 with o2sat 75% on 100%fio2. meds: unknown anxiolytic, estrogen. pmh: pud, ?stroke and memory difficulty in the past 1-2 years. fhx: unknown. shx: divorced. unknown history of tobacco/etoh/illicit drug use. exam: bp126/91, hr86, rr 30, 37.1c.ms: oriented to name only. speech without dysarthria. 2/3 recall at 5minutes.cn: unremarkable.motor: full strength throughout with normal muscle tone and bulk.sensory: unremarkable.coord/station: unremarkable.gait: not tested on admission.gen exam: notable for erythema of the face and chest. course: she underwent a total of four dives under hyperbaric oxygen ( 2 dives on 1/17 and 2 dives on 1/18). neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. she was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. she progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. she became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. she was later transferred to another care facility against medical advice. the etiology for these changes became complicated by a newly discovered history of possible etoh abuse and usual &quot;anxiety&quot; disorder. mri brain, 2/14/96, revealed increased t2 signal within the periventricular white matter, bilaterally. eeg showed diffuse slowing without epileptiform activity."
+"identifying data:  the patient is a 45-year-old white male.  he is unemployed, presumably on disability and lives with his partner. chief complaint:  &quot;i&#8217;m in jail because i was wrongly arrested.&quot; the patient is admitted on a 72-hour involuntary treatment act for grave disability. history of present illness:  the patient has minimal insight into the circumstances that resulted in this admission.  he reports being diagnosed with aids and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition.  prior to admission, the patient was brought to emergency room after he attempted to shoplift from a local department store, during which he apparently slapped his partner.  the patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour involuntary treatment act for grave disability. on the interview, the patient is still disorganized and confused.  he believes that he has been arrested and is in jail.  reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary. i was able to contact his partner by telephone.  his partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers.  his partner estimates the patient spends about 20% of the year in episodes of worse symptoms.  his partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons.  he also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night.  he also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently.  he also reports that the patient has been making threats of harm to him and that his partner no longer feels that he is safe having him at home.  he reports that the patient has been eating regularly with no recent weight loss.  he states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months.  his partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening.  he reports of the patient&#8217;s longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient&#8217;s dislike of taking medicine.  he also reports that the patient has expressed the belief in the past that he does not suffer from either condition. past psychiatric history:  the patient&#8217;s partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown.  the patient was last enrolled in an outpatient mental health treatment in mid 2009.  he dropped out of care about six months ago when he moved with his partner.  his partner reports the patient was most recently prescribed seroquel, which, though the patient denied benefiting from, his partner felt was &quot;useful, but not dosed high enough.&quot; past medication trials that the patient reports include haldol and lithium, neither of which he found to be particularly helpful. medical history:  the patient reports being diagnosed with hiv and aids in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis.  he is currently followed at clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year.  the patient is fairly vague on his history of aids related conditions, but does identify the following:  thrush, skin lesions, and lung infections; additional details of these problems are not currently known. current medications:  none. allergies:  no known drug allergies. social and developmental history:  the patient lives with his partner.  he is unemployed.  details of his educational and occupational history are not currently known.  his source of finances is also unknown, though social security disability is presumed. substance and alcohol history:  the patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month.  his partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently.  the patient reports smoking marijuana a few times in his life, but not recently.  denies other illicit substance use. legal history:  unknown. genetic psychiatric history:  also unknown. mental status exam:attitude:  the patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions.  his appearance is cachectic.  the patient is poorly groomed.psychomotor:  there is no psychomotor agitation or retardation.  no other observed extrapyramidal symptoms or tardive dyskinesia.affect:  his affect is fairly detached.mood:  describes his mood is &quot;okay.&quot;speech:  his speech is normal rate and volume.  tone, his volume was decreased initially, but this improved during the course of the interview.thought process:  his thought processes are markedly tangential.thought content:  the patient is fairly scattered.  he will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time.  he denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline.  paranoid delusions are elicited.homicidal/suicidal ideation:  he denies suicidal or homicidal ideation.  denies previous suicide attempts.cognitive assessment:  cognitively, he is alert and oriented to person and year only.  his memory is intact to names of his madison clinic providers.insight/judgment:  his insight is absent as evidenced by his repeated questioning of the validity of his aids and mental health diagnoses.  his judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.assets:  his assets include his housing and his history of supportive relationship with his partner over many years.limitations:  his limitations include his aids and his history of poor compliance with treatment. formulation:  the patient is a 45-year-old white male with a history of schizophrenia and aids.  he was admitted for disorganized and assaultive behaviors while off all medications for the last six months.  it is unclear to me how much his presentation is a direct expression of an aids-related condition, though i suspect the impact of his hiv status is likely to be substantial. diagnoses:axis i:  schizophrenia by history.  rule out aids-induced psychosis.  rule out aids-related cognitive disorder.axis ii:  deferred.axis iii:  aids (stable by his report).  anemia.axis iv:  relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and hiv-related providers.axis v:  global assessment functioning is currently 15. plan:  i will attempt to increase the database, will specifically request records from the last mental health providers.  the internal medicine service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at clinic regarding issues related to his aids diagnosis.  with the patient&#8217;s permission, i will start quetiapine at a dose of 100 mg at bedtime, given the patient&#8217;s partner report of partial, but response to this agent in the past.  i anticipate titrating further for effect during the course of his admission."
+"cc: progressive memory and cognitive decline. hx: this 73 y/o rhf presented on 1/12/95, with progressive memory and cognitive decline since 11/94. her difficulties were first noted by family the week prior to thanksgiving, when they were taking her to vail, colorado to play &quot;murder she wrote&quot; at family gathering. unbeknownst to the patient was the fact that she had been chosen to be the &quot;assassin.&quot; prior to boarding the airplane her children hid a toy gun in her carry-on luggage. as the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. she and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. in prior times they would have expected her to have brushed off the incident with a &quot;chuckle.&quot; while in colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing &quot;murder she wrote.&quot; she needed assistance to complete the game. the family noted no slurring of speech, difficulty with vision, or focal weakness at the time. she returned to work at a local florist shop the monday following thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. she quit working the next day and never went back. her mental status appeared to remain relatively stable throughout the month of november and december and during that time she was evaluated by a local neurologist. serum vdrl, tfts, gs, b12, folate, cbc, cxr, and mri of the brain were all reportedly unremarkable. the working diagnosis was &quot;dementia of the alzheimer&#8217;s type.&quot; one to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. in addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. furthermore, she began expressing emotional lability unusual for her. she also tended to veer toward the right when walking and often did not recognize the location of people talking to her. meds: none. pmh: unremarkable. fhx: father and mother died in their 80&#8242;s of &quot;old age.&quot; there was no history of dementing illness, stroke, htn, dm, or other neurological disease in her family. she has 5 children who were alive and well. shx: she attained a high school education and had been widowed for over 30 years. she lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. she had no history of tobacco, alcohol or illicit drug use. exam: vitals signs were within normal limits. ms: a&#038;o to person place and time. at times she seemed in absence. she scored 20/30 on mmse and had difficulty with concentration, calculation, visuospatial construction. her penmanship was not normal, and appeared &quot;child-like&quot; according to her daughters. she had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. in addition, while attempting to write, she had difficulty finding the right margin of the page. cn: right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. the rest of the cn exam was unremarkable. motor: 5/5 strength throughout with normal muscle tone and bulk. sensory: extinguishing of rue sensation on double simultaneous stimulation, and at times she appeared to show sign of rue neglect. there were no unusual spontaneous movements noted. coord: unremarkable except for difficulty finding the target on fnf exercise when the target was moved into the right side visual field. station: no sign of romberg or pronator drift. there was no truncal ataxia. gait: decreased rue swing and a tendency to veer and circumambulate to the right when asked to walk toward a target. reflexes: 2/2 and symmetric throughout all four extremities. plantar responses were equivocal, bilaterally. course:  cbc, gs, pt, ptt, esr, ua, crp, tsh, ft4, and ekg were unremarkable. csf analysis revealed: 38 rbc, 0 wbc, protein 36, glucose 76. the outside mri was reviewed and was found to show increased signal on t2 weighted images in the gyri of the left parietal-occipital regions. repeat mri, at uihc, revealed the same plus increased signal on t2 weighted images in the left frontal region as well. cxr, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. a 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. the working diagnosis became creutzfeldt-jakob disease (heidenhaim variant). the patient died on 2/15/95. brain tissue was sent to the university of california at san francisco. analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. this vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. hydrolytic autoclaving technique was used with prp-specific antibodies to identify the presence of protease resistant prp (cjd). the patient&#8217;s brain tissue was strongly positive for prp (cjd)."
+"cc: difficulty with speech. hx: this 72 y/o rhm awoke early on 8/14/95 to prepare to play golf. he felt fine. however, at 6:00am, on 8/14/95, he began speaking abnormally. his wife described his speech as &quot;word salad&quot; and &quot;complete gibberish.&quot; she immediately took him to a local hospital . enroute, he was initially able to understand what was spoken to him. by the time he arrived at the hospital at 6:45am, he was unable to follow commands. his speech was reportedly unintelligible the majority of the time, and some of the health care workers thought he was speaking a foreign language. there were no other symptoms or signs. he had no prior history of cerebrovascular disease. blood pressure 130/70 and pulse 82 upon admission to the local hospital on 8/14/95. evaluation at the local hospital included: 1)hct scan revealed an old left putaminal hypodensity, but no acute changes or evidence of hemorrhage, 2) carotid duplex scan showed ica stenosis of 40%, bilaterally. he was placed on heparin and transferred to uihc on 8/16/95. in addition, he had noted memory and word finding difficulty for 2 months prior to presentation. he had undergone a gastrectomy 16 years prior for peptic ulcer disease. his local physician found him vitamin b12 deficient and he was placed on vitamin b12 and folate supplementation 2 months prior to presentation. he and his wife felt that this resulted in improvement of his language and cognitive skills. meds: heparin iv, vitamin b12 injection q. week, lopressor, folate, mvi. pmh: 1)hypothyroidism (reportedly resolved), 2) gastrectomy, 3)vitamin b12 deficiency. fhx: mother died of mi, age 70. father died of prostate cancer, age 80. bother died of cad and prostate cancer, age 74. shx: married. 3 children who are alive and well. semi-retired attorney. denied h/o tobacco/etoh/illicit drug use. exam: bp 110/70, hr 50, rr 14, afebrile. ms: a&#038;o to person and place, but not time. oral comprehension was poor beyond the simplest of conversational phrases. speech was fluent, but consisted largely of &quot;word salad.&quot; when asked how he was, he replied: &quot;abadeedleedlebadle.&quot; repetition was defective, especially with long phrases. on rare occasions, he uttered short comments appropriately. speech was marred by semantic and phonemic paraphasias. he named colors and described most actions well, although he described a &quot;faucet dripping&quot; as a &quot;faucet drop.&quot; he called &quot;red&quot; &quot;reed.&quot; reading comprehension was better than aural comprehension. he demonstrated excellent written calculations. spoken calculations were accurate except when the calculations became more complex. for example, he said that ten percent of 100 was equal to &quot;1,200.&quot; cn: pupils 2/3 decreasing to 1/1 on exposure to light. vfftc. there were no field cuts or evidence of visual neglect. eom were intact. face moved symmetrically. the rest of the cn exam was unremarkable. motor: full strength throughout with normal muscle tone and bulk. there was no evidence of drift. sensory: unremarkable. coord: unremarkable. station: unremarkable. gait: mild difficulty with tw. reflexes: 2/2 in bue. 2/2+ patellae, 1/1 achilles. plantar responses were flexor on the left and equivocal on the right. gen exam: unremarkable. course: lab data on admission: glucose 97, bun 20, na 134, k 4.0, cr 1.3, chloride 98, co2 24, pt 11, ptt 42, wbc 12.0 (normal differential), hgb 11.4, hct 36%, plt=203k. ua normal. tsh 6.0, ft4 0.88, vit b12 876, folate 19.1. he was admitted and continued on heparin. mri scan, 8/16/95, revealed increased signal on t2-weighted images in wernicke&#8217;s area in the left temporal region. transthoracic echocardiogram on 8/17/95 was unremarkable. transesophageal echocardiogram on 8/18/95 revealed a sclerotic aortic valve and myxomatous degeneration of the anterior leaflet of the mitral valve. lae 4.8cm, and spontaneous echo contrast in the left atrium were noted. there was no evidence of intracardiac shunt or clot. carotid duplex scan on 8/16/95 revealed 0-15% bica stenosis with anterograde vertebral artery flow, bilaterally. neuropsychologic testing revealed a wernicke&#8217;s aphasia. the impression was that the patient had had a cardioembolic stroke involving a lower-division branch of the left mca. he was subsequently placed on warfarin. thoughout his hospital stay he showed continued improvement of language skills and was enrolled in speech therapy following discharge, 8/21/95. he has had no further stroke like episodes up until his last follow-up visit in 1997."
+"preoperative diagnoses:1.  protein-calorie malnutrition.2.  intractable nausea, vomiting, and dysphagia. postoperative diagnoses:1.  protein-calorie malnutrition.2.  intractable nausea, vomiting, and dysphagia.3.  enterogastritis. procedure performed:  egd with peg tube placement using russell technique. anesthesia:  iv sedation with 1% lidocaine for local. estimated blood loss:  none. complications:  none. brief history:  this is a 44-year-old african-american female who is well known to this service.  she has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  she states that her decreased p.o. intake has been progressively worsening.  she was admitted to the service of dr. lang and was evaluated by dr. wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a peg tube. procedure:  after risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  she was placed in the supine position.  the area was prepped and draped in the sterile fashion.  after adequate iv sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  the esophagus, stomach, and duodenum were visualized without difficulty.  there was no gross evidence of any malignancy.  there was some enterogastritis which was noted upon exam.  the appropriate location was noted on the anterior wall of the stomach.  this area was localized externally with 1% lidocaine.  large gauge needle was used to enter the lumen of the stomach under visualization.  a guide wire was then passed again under visualization and the needle was subsequently removed.  a scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  a dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  the guidewire and dilator were then removed again under visualization and the peg tube was placed through the break-away sheath and visualized within the lumen of the stomach.  the balloon was then insufflated and the break-away sheath was then pulled away.  proper placement of the tube was ensured through visualization with a scope.  the tube was then sutured into place using nylon suture.  appropriate sterile dressing was applied. disposition:  the patient was transferred to the recovery in a stable condition.  she was subsequently returned to her room on the general medical floor.  previous orders will be resumed.  we will instruct the nursing that the peg tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings."
+"preoperative diagnoses:1.  gastroesophageal reflux disease.2.  chronic dyspepsia. postoperative diagnoses:1.  gastroesophageal reflux disease.2.  chronic dyspepsia.3.  alkaline reflux gastritis.4.  gastroparesis.5.  probable billroth ii anastomosis.6.  status post whipple&#8217;s pancreaticoduodenectomy. procedure performed:  esophagogastroduodenoscopy with biopsies. indications for procedure:  this is a 55-year-old african-american female who had undergone whipple&#8217;s procedure approximately five to six years ago for a benign pancreatic mass.  the patient has pancreatic insufficiency and is already on replacement.  she is currently using nexium.  she has continued postprandial dyspepsia and reflux symptoms.  to evaluate this, the patient was boarded for egd.  the patient gave informed consent for the procedure. gross findings:  at the time of egd, the patient was found to have alkaline reflux gastritis.  there was no evidence of distal esophagitis.  gastroparesis was seen as there was retained fluid in the small intestine.  the patient had no evidence of anastomotic obstruction and appeared to have a billroth ii reconstruction by gastric jejunostomy.  biopsies were taken and further recommendations will follow. procedure:  the patient was taken to the endoscopy suite.  the heart and lungs examination were unremarkable.  the vital signs were monitored and found to be stable throughout the procedure.  the patient&#8217;s oropharynx was anesthetized with cetacaine spray.  she was placed in left lateral position.  the patient had the video olympus gif gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  ge junction was in normal position.  there was no evidence of any hiatal hernia.  there was no evidence of distal esophagitis.  the gastric remnant was entered.  it was noted to be inflamed with alkaline reflux gastritis.  the anastomosis was open and patent.  the small intestine was entered.  there was retained fluid material in the stomach and small intestine and _______ gastroparesis.  biopsies were performed.  insufflated air was removed with withdrawal of the scope.  the patient&#8217;s diet will be adjusted to postgastrectomy-type diet.  biopsies performed.  diet will be reviewed.  the patient will have an upper gi series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  reglan will also be added.  further recommendations will follow."
+"preprocedure diagnosis:  colon cancer screening. postprocedure diagnosis:  colon polyps, diverticulosis, hemorrhoids. procedure performed:  colonoscopy, conscious sedation, and snare polypectomy.   indications:  the patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  he has had previous colonoscopy.  there is no family history of bleeding, no current problems with his bowels.  on examination, he has internal hemorrhoids.  his prostate is enlarged and increased somewhat in firmness.  he has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  these were removed with snare polypectomy technique.  i would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding. procedure:  after explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg versed intravenously for conscious sedation.  blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  a rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  the scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  the scope was withdrawn into the left transverse colon, where the second polyp was identified.  it was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  the scope was then gradually withdrawn the remaining distance and removed.  the patient tolerated the procedure well."
+"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 findingsgeneral:  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&#8217;s care."
+"procedure:  left heart catheterization, left ventriculography, coronary angiography, and successful stenting of tight lesion in the distal circumflex and moderately tight lesion in the mid right coronary artery.  this gentleman has had a non-q-wave, troponin-positive myocardial infarction, complicated by ventricular fibrillation. procedure details:  the patient was brought to the catheterization lab, the chart was reviewed, and informed consent was obtained.  right groin was prepped and draped sterilely and infiltrated 2% xylocaine.  using the seldinger technique, a #6-french sheath was placed in the right femoral artery.  act was checked and was low.  additional heparin was given.  a #6-french pigtail catheter was passed.  left ventriculography was performed.  the catheter was exchanged for a #6-french jl4 catheter.  nitroglycerin was given in the left main.  left coronary angiography was performed.  the catheter was exchanged for a #6-french __________ coronary catheter.  nitroglycerin was given in the right main, and right coronary angiography was performed.  films were closely reviewed, and it was felt that he had a significant lesion in the rca and the distal left circumflex is basically an om.  considering his age and his course, it was elected to stent both these lesions.  reopro was started, and the catheter was exchanged for a #6-french jr4 guide.  reopro was given in the rca to prevent no reflow.  a 0.014 universal wire was passed.  the lesion was measured.  a 4.5 x 18-mm stent was passed and deployed to moderate pressures with an excellent result.  the catheter was removed and exchanged for a #6-french jl4 guide.  the same wire was passed down the circumflex and the lesion measured.  a 2.75 x 15-mm stent was deployed to a moderate pressure with an excellent result.  plavix was given.  the catheter was removed and sheath was in place.  the results were explained to the patient and his wife. findings1.  hemodynamics.  please  see attached sheet for details.  ed was 20.  there is no gradient across the aortic valve.2.  left ventriculography revealed septum upper limits of normal size with borderline normal lv systolic function with borderline normal wall motion, in which there is a question of  diffuse, very minimal global hypokinesis.  there is mild mr noted.3.  coronary angiography.a.  left main normal.b.  lad.  some very minimal luminal irregularities.  there is a 1st diagonal which has a branch that is 1.5 mm with a proximal 50% narrowing.c.  left circumflex is basically a marginal branch, in which distally there was a long 98% lesion.d.  the rca is large dominant and has a mid somewhat long 70% lesion.4.  stenting.a.  the rca revealed a lesion that went from 70% to a -5%.b.  the circumflex went from 95% to -5%. conclusion1.  decreased left ventricular compliance.2.  borderline normal overall ejection fraction with mild mitral regurgitation.3.  triple-vessel coronary artery disease with a borderline lesion in a very small branch of the 1st diagonal and significant lesions in the mid dominant right coronary artery and the distal circumflex, which is basically old.4.  successful stenting of the right coronary artery and the circumflex. recommendation:  reopro/stent protocol, plavix for at least 9 months, aggressive control of risk factors.  i have ordered zocor and a fasting lipid panel. aicd will be considered, realizing when this gentleman becomes ischemic he is at high risk for fibrillating."
+"<strong>procedure:</strong> diagnostic fiberoptic bronchoscopy. <strong>anesthesia: </strong>plain lidocaine 2% was given intrabronchially for local anesthesia. <strong>preoperative medications:</strong> 1. lortab (10 mg) plus phenergan (25 mg), p.o. 1 hour before the procedure. 2. versed a total of 5 mg given iv push during the procedure. <strong>indications: </strong>right upper lobe lung mass, posterior segment. consent obtained from the patient&#8217;s daughter. <strong>procedure in detail:</strong> after appropriate sedation was achieved, the bronchoscope was introduced via the right nares and advanced to the upper larynx. plain lidocaine 2% was used to anesthetize the laryngeal structures. after adequate anesthesia was achieved, close inspection of the laryngeal structures could be performed. both vocal cords moved appropriately. under direct visualization, the bronchoscope was advanced past the vocal cords and into the distal trachea. additional 2% plain lidocaine was used in the trachea and the main stem bronchi for anesthesia. after adequate anesthesia was achieved, close inspection of the airways could be undertaken. the left tracheobronchial tree was inspected closely to the level of the subsegmental bronchi. all bronchi are patent with no endobronchial lesions and no mucosal lesions noted. the right tracheobronchial tree was also patent and intact with the mucosa normal. the bronchoscope was then introduced to the right upper lobe specifically to the posterior segment and washings/brushings and transbronchial lung biopsies were taken from that area. he had quite a bit of coughing during the diagnostic procedures despite lidocaine administration. a total of 5 mg of versed was used to effect sedation. at one point, the bronchoscope had to be completely withdrawn so that the sample could be appropriately retrieved. upon reintroduction, there was quite a bit of bleeding in his right nares. the right naris was packed for control of the bleeding. the procedure was completed and all samples were submitted for appropriate studies. a post procedure chest x-ray has been obtained and is still pending. he tolerated the procedure very well other then for the brisk epistaxis from the right nares. packing to the right nares has been completed."
+"reason for exam:1.  angina.2.  coronary artery disease. interpretation:  this is a technically acceptable study. dimensions:  anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  the left atrium is 3.9. findings:    left atrium was mildly to moderately dilated.  no masses or thrombi were seen.  the left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  the ef was moderately reduced with estimated ef of 40% with near normal thickening.  the right atrium was mildly dilated.  the right ventricle was normal in size. mitral valve showed to be structurally normal with no prolapse or vegetation.  there was mild mitral regurgitation on color flow interrogation.  the mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  the aortic valve appeared to be structurally normal.  normal peak velocity.  no significant ai.  pulmonic valve showed mild pi.  tricuspid valve showed mild tricuspid regurgitation.  based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmhg.  anterior septum appeared to be intact.  no pericardial effusion was seen. conclusion:1.  mild biatrial enlargement.2.  normal thickening of the left ventricle with mildly dilated ventricle and ef of 40%.3.  mild mitral regurgitation.4.  diastolic dysfunction grade 2.5.  mild pulmonary hypertension."
+"reason for consult:  altered mental status. hpi:  the patient is 77-year-old caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the physical medicine and rehab service for inpatient rehab after suffering a right cerebellar infarct last month.  last night, he became confused and he eloped from the unit.  when he was found, he became combative.  this a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to haldol 1 mg intramuscularly.  there was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital.  given this presentation, psychiatry was consulted to evaluate and offer management recommendations. the patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications.  he reports feeling fine currently, denying any complaints.  the patient&#8217;s wife notes that her husband might be confused and disoriented due to being in the hospital environment.  she admits that he has some difficulty with memory for sometime and becomes irritable when she is not around.  however, he has never become as combative as he has this particular episode. he negates any symptoms of depression or anxiety.  he also denies any hallucinations or delusions.  he endorses problems with insomnia.  at home, he takes temazepam.  his wife and son note that the temazepam makes him groggy and disoriented at times when he is at home. past psychiatric history:  he denies any prior psychiatric treatment or intervention.  however, he was placed on zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia.  during this hospital course, he was started on seroquel 20 mg p.o. q.h.s. in addition to aricept 5 mg daily.  he denies any history of suicidal or homicidal ideations or attempts. past medical history:1.  heart transplant in 1997.2.  history of abdominal aortic aneurysm repair.3.  diverticulitis.4.  cholecystectomy.5.  benign prostatic hypertrophy. allergies:  morphine and demerol. medications:1.  seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.2.  imodium 2 mg p.o. p.r.n., loose stool.3.  calcium carbonate with vitamin d 500 mg b.i.d.4.  prednisone 5 mg p.o. daily.5.  bactrim ds monday, wednesday, and friday.6.  flomax 0.4 mg p.o. daily.7.  robitussin 5 ml every 6 hours as needed for cough.8.  rapamune 2 mg p.o. daily.9.  zoloft 50 mg p.o. daily.10.  b vitamin complex daily.11.  colace 100 mg b.i.d.12.  lipitor 20 mg p.o. q.h.s.13.  plavix 75 mg p.o. daily.14.  aricept 5 mg p.o. daily.15.  pepcid 20 mg p.o. daily.16.  norvasc 5 mg p.o. daily.17.  aspirin 325 mg p.o. daily. social history:  the patient is a retired paster and missionary to mexico.  he is still actively involved in his church.  he denies any history of alcohol or substance abuse. mental status examination:  he is an average-sized white male, casually dressed, with wife and son at bedside.  he is pleasant and cooperative with good eye contact.  he presents with paucity of speech content; however, with regular rate and rhythm.  he is tremulous which is worse with posturing also some increased motor tone noted.  there is no evidence of psychomotor agitation or retardation.  his mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content.  his thoughts are circumstantial but logical.  he defers most of his responses to his wife.  there is no evidence of suicidal or homicidal ideations.  no presence of paranoid or bizarre delusions.  he denies any perceptual abnormalities and does not appear to be responding to internal stimuli.  his attention is fair and his concentration impaired.  he is oriented x3 and his insight is fair.  on mini-mental status examination, he has scored 22 out of 30.  he lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s.  on category fluency, he was able to name 17 animals in one minute.  he was unable to draw clock showing 2 minutes after 10.  his judgment seems limited. laboratory data:  calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, ptt 24.8, pt 14.1, inr 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000.  urinalysis on january 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase. diagnostic data:  mri of brain with and without contrast done on january 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes. assessment:axis i:1.  delirium resulting due to general medical condition versus benzodiazepine intoxication/withdrawal.2.  cognitive disorder, not otherwise specified, would rule out vascular dementia.3.  depressive disorder, not otherwise specified.axis ii:  deferred.axis iii:  see patient&#8217;s problem list.axis iv:  problems with life changes and chronic medical illness.axis v:  gaf is 55. impression:  the patient is a 77-year-old gentleman with multiple medical problems, status post cerebellar stroke with episodic altered mental status, mostly at evening time with probable underlying cognitive decline. recommendations:  1.  encouraged liberal family visitation and frequent verbal redirection by nursing staff to help keep patient oriented.2.  we would discontinue temazepam and refrain from using other benzodiazepines in this elderly patient as it may cause paradoxical confusion.3.  we changed seroquel to 12.5 mg p.o. at noon, 25 mg p.o. at 5 p.m., and 25 mg p.o. q.h.s. as confusion seems to be more prominent at night time and would not want to impair his ability to function in therapy during the daytime.4.  for breakthrough agitation, we recommend zyprexa zydis 5 mg p.o. q.8h. p.r.n. for severe agitation.5.  above case and recommendations discussed with dr. ranjit chacko.6.  appreciate consults, please contact with any further questions."
+"problem:  chronic abdominal pain, nausea, vomiting, abnormal liver function tests. history:  the patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient&#8217;s recent move from eugene to portland.  the patient is not a great historian.  most of the history is obtained through the old history and chart that the patient has with her.  according to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  she was initially seen by dr. a back in september 2001 for abdominal pain, nausea and vomiting.  during those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in oregon by dr.  a in august 2001.  it was assumed that this was caused by biliary dyskinesia.  previous to that, an upper endoscopy was performed by dr. b in july 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.    in addition, she had significant abnormal liver function tests with alt in the 600&#8242;s, ast 300&#8242;s with a bilirubin 2.5 and alkaline phosphatase in the 200&#8242;s.  ultrasound shows common bile duct of 6 mm post cholecystectomy.  the patient was then eventually referred to dr. w in oregon.  given the abnormal liver function tests and abnormal ultrasound, dr. w performed an ercp with sphincterotomy  in september 20, 2001.  because of the symptoms and the suspicions of sphincter of oddi dysfunction, a sphincterotomy was performed during the ercp.  procedure was uneventful.  the patient did well for a few months, but unfortunately got hospitalized again in may 2002 for recurrence of the abdominal pain and markedly elevated liver function tests with alt in the 600 to 900 range, again with nausea and vomiting.  after transient elevation, her liver function tests would normalize.   during her hospitalization, extensive work-up including ct scan, 24 hour urine collection for porphyrins, a percutaneous liver biopsy, and hepatitis panel, all of which were normal.  a repeat ercp with placement of endobiliary stent was uneventful and did not show evidence of pbc or psc.  after placement of the biliary stent, according to dr. w&#8217;s note, it apparently helped the patient with her symptoms with decreased frequency of nausea, vomiting, and pain.  mri of the abdomen was also performed in may 2002 showing a horseshoe kidney, which was previously known on old ct scans.  while the biliary stent was in place, the patient did have recurrent bouts of nausea and vomiting and pain rated 7 out of 10 in intensity.   finally in august 2002, the endobiliary stent was removed and there were no signs of obstruction.  thereafter, the patient actually did fairly well for about a year, but because of a recurrence of her symptoms, dr. w actually sent the patient up to ohsu for evaluation of this continued fairly mysterious abdominal pain.  the patient states that she saw dr. a who recommended some laboratory tests and a repeat ercp for further evaluation, but the patient did not want to go up to ohsu as she was somewhat unhappy with initial care.   then, over the course of the next several month, at the beginning of 2004, the patient&#8217;s symptoms of nausea, vomiting, and recurrence abdominal pain returned.  in fact, recently as the last documentation in may and june, the patient visited emergency room several times due to her symptoms.  lab tests show normal cbc with no signs of elevated white count.  ast and alt were normal.  alkaline phosphatase was in the low 200&#8242;s with minimally elevated lipase of 78.  bilirubin was completely normal.  the patient was given some zofran and that seemed to control her symptoms and then she was discharged and now referred to us for further evaluation.  at the present time, the patient is not having any abdominal pain.  she states she threw up three times in the morning and is feeling well at this point.  her abdominal pain, nausea and vomiting symptoms are random.  it does not associate with food.  it is not pre or post meal and occasionally will wake her up in the middle of the night.  she has not lost any weight despite this chronic nausea and vomiting and abdominal pain.  her bowel habits have been fairly normal.  no hematemesis or melena.  no rashes, joint pain, or other symptoms have been noted.   allergies:  the patient has allergies to sulfa and codeine.   operations:  laparoscopic cholecystectomy, two ercp&#8217;s including stent placement and sphincterotomy. illnesses:  juvenile rheumatoid arthritis for which dr. b is following. medications:  the patient is on some type of anti-inflammatory, for which the name is unknown to her.  she is also taking some zofran.   habits:  she does not drink or smoke.   social history:  the patent moved up from eugene.  she currently lives up here and works in portland.   family history:  noncontributory. review of systems:  the patient has seen primarily dr. b, her rheumatologist, as primary care. data:  the patient&#8217;s extensive chart was reviewed.  it took over 45 minutes to sort through the chart and the labs.  physical examination:   the patient is a  23-year old female who appears well developed with no acute signs of distress.  hent:  normocephalic, atraumatic, perrla, eomi, sclerae are anicteric.  nares are patent and symmetrical.  the oropharynx is clear with moist mucus membranes and no obvious mucosal lesions.  the tongue is midline.  neck:  supple without adenopathy, jvd, or thyromegaly.  there&#8217;s no supraclavicular adenopathy.  lungs:  clear bilaterally with normal respiratory effort.  back:  nontender to palpation and there&#8217;s no cva tenderness or obvious spinal deformity.  cardiac:  regular rate and rhythm. no murmur.  abdomen:  soft, nondistended and nontender to palpation throughout with no appreciable hepatosplenomegaly, masses, fullness or ascites.  bowel sounds were present and did appear normal.  rectal:  deferred.  extremities:  without edema, calf tenderness or joint swelling.  neurologic:  shows the patient to be alert and oriented x&#8217;s 3 with normal gait.  skin:  warm and dry with normal color and no rashes.  impression:  a 23-year-old female with fairly mysterious symptoms of nausea, vomiting, and abdominal pain status post cholecystectomy and ercp with sphincterotomy.  she continues to have very intermittent elevated liver function tests and symptoms of nausea, vomiting, and abdominal pain.  there was some discussion with dr. w in the past regarding extending the sphincterotomy to ensure that a complete sphincterotomy was performed if the patient should have sphincter of oddi dysfunction, however, at this time i am reluctant to do so without further reviewing the patient&#8217;s chart and investigating other avenues.  i think we will check another repeat liver function test and i think it may be helpful to repeat a liver biopsy to ensure we are not missing other primary liver diseases before concentrating purely on the biliary tree itself.  in addition, ama will be obtained along with a liver function test.  i would also like to obtain some discharge summaries from dr. w&#8217;s office to further clarify what has transpired over the past three years.   plan:  1.  obtain discharge summaries from dr. w&#8217;s office.2.  send the patient for a complete metabolic panel, ama.3.  send the patient for ultrasound and possible ultrasound guided liver biopsy.4.  the patient will return to see me in three weeks.  we will consider further options pending on these results of the test and review of the patient&#8217;s discharge summaries from dr. w&#8217;s office.  if the patient should show symptoms of pain and elevated liver function tests to be consistent with sphincter of oddi dysfunction, we may repeat the ercp and extend the sphincterotomy.  the entire case was discussed with the patient.  the patient is agreeable to the current plan.  thank you for this consultation.   followup:  in two to three weeks."
+"history of present illness:  patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank &quot;lots of red wine.&quot;  she states after vomiting, she felt &quot;fine through the night,&quot; but woke with more nausea and vomiting and diaphoresis.  she states she has vomited approximately 20 times today and has also had some slight diarrhea.  she denies any sore throat or cough.  she states no one else at home has been ill.  she has not taken anything for her symptoms. medications:  currently the patient is on fluoxetine for depression and zyrtec for environmental allergies. allergies:  she has no known drug allergies. social history:  the patient is married and is a nonsmoker, and lives with her husband, who is here with her. review of systemspatient denies any fever or cough.  she notes no blood in her vomitus or stool.  the remainder of her review of systems is discussed and all are negative. nursing notes were reviewed with which i agree. physical examinationvital signs:  temp is 37.6.  other vital signs are all within normal limits.general:  patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.heent:  head is normocephalic and atraumatic.  pharynx shows no erythema, tonsillar edema, or exudate.  neck:  no enlarged anterior or posterior cervical lymph nodes.  there is no meningismus.heart:  regular rate and rhythm without murmurs, rubs, or gallops.lungs:  clear without rales, rhonchi, or wheezes.abdomen:  active bowel sounds.  soft without any focal tenderness on palpation.  there are no masses, guarding, or rebound noted.skin:  no rash.extremities:  no cyanosis, clubbing, or edema. laboratory data:  cbc shows a white count of 12.9 with an elevation in the neutrophil count on differential.  hematocrit is 33.8, but the indices are normochromic and normocytic.  bmp is remarkable for a random glucose of 147.  all other values are unremarkable.  lfts are normal.  serum alcohol is less than 5. treatment:  patient was given 2 l of normal saline wide open as well as compazine 5 mg iv x2 doses with resolution of her nausea.  she was given two capsules of imodium with some apple juice, which she was able to keep down.  the patient did feel well enough to be discharged home. assessment:  viral gastroenteritis. plan:  rx for compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  she was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  if she is unimproved in the next two days, she was urged to follow up with her pcp back home."
+"reason for consultation: acute renal failure. history:  limited data is available; i have reviewed his admission notes. apparently this man was found down by a family member, was taken to medical center, and subsequently flown here. he has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. markers of renal function have been fairly stable. i do not presently see indicators that he historically has been oliguric. the bun and creatinine have been fairly stable. it is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. earlier thoughts had been that he could have had rhabdomyolysis, but the highest cpk i find recorded is 1500, the phosphorus is not elevated, though i acknowledge the serum calcium is low. i see no markers of myoglobinuria nor serum level of myoglobin. he has received iv fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition. past medical history: not obtained from the patient, but is reviewed in other physician&#8217;s notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking imdur and digoxin, reportedly. a suggestion of hypertensive disease versus bph, he was on terazosin. suggestion of chf versus hypertension versus volume overload, treated with lasix. he was iron, i presume for anemia. he was on potassium, lisinopril and aspirin. allergies: other physician&#8217;s notes indicate no known allergies. family history: not available. social history: not available. review of systems: not available. physical examination:general: an older white male who is intubated, edematous, and appears uncomfortable.heent: male pattern baldness. pupils equally round, no icterus. intubated. og tube in place.neck: not tested for suppleness, no carotid bruits are heard. neck vein distention is not seen.lungs: he has diffuse expiratory wheezing anteriorly, laterally and posteriorly. i would describe the wheezes as coarse. i hear no present rales. breath sounds otherwise are symmetrical.heart: heart tones regular to auscultation, currently without audible rub or gallop sounds.breasts: not enlarged.abdomen: on plane. bowel sounds presently are normal. abdomen, i believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no hjr, no spleen tip, no suprapubic fullness.gu: catheter draining a dark yellow urine.extremities: very edematous. pulses not palpable. cyanosis not observed. fungal changes are not observed.neurological: not otherwise assessed. laboratory data: reviewed. impression:1. acute renal failure, suspected. likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. he also reportedly was on lasix prior to hospitalization, ? hypovolemia as a consequence.2. multi-organ system failure/systemic inflammatory response syndrome, with septic shock.3. i am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum ck recorded is 1500.4. antecedent hypoxemia, with renal hypoperfusion.5. diffuse aspiration pneumonitis suggested. discussion/plan: i think the renal function will follow the patient. supportive care, attention to stability of a euvolemic state, will be important at this time. he is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. he is on tpn, antimicrobials, and has been on vasopressive agents. blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission. i would use diuretics to maintain central euvolemia. recorded i&#8217;s are substantially o&#8217;s during the course of the hospitalization, i presume as part of his resuscitation effort. no central pressures or monitoring of same is currently available. i will follow with you. no present indication for hemodialysis. antimicrobials are being handled by others."
+"referral indication and preprocedure diagnoses1.  dilated cardiomyopathy.2.  ejection fraction less than 10%.3.  ventricular tachycardia.4.  bradycardia with likely high degree of pacing. procedures planned and performed1.  implantation of biventricular automatic implantable cardioverter defibrillator.2.  fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.3.  coronary sinus venogram for left ventricular lead placement.4.  defibrillation threshold testing x2. fluoroscopy time:  18.5 minutes. medications at the time of study1.  vancomycin 1 g (the patient was allergic to penicillin).2.  versed 10 mg.3.  fentanyl 100 mcg.4.  benadryl 50 mg. clinical history:  the patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for aicd implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  he has underlying sinus bradycardia.  therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device. risks and benefits:  risks, benefits, and alternatives to implantation of biventricular aicd and defibrillation threshold testing were discussed with the patient.  risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  the patient agreed both verbally and via written consent. description of procedure:  the patient was transported to the cardiac catheterization laboratory in the fasting state.  the region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  lidocaine 1% (20 ml) was administered to the area.  after achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  guidewires were advanced down into the left axillary vein.  following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  hemostasis was achieved with electrocautery.  lidocaine 1% (10 ml) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  using the more lateral of the guidewires, a 7-french side-arm sheath was advanced into the left axillary vein.  the dilator was removed and another wire was advanced down into the sheath.  the sheath was then backed up over the top of the two wires.  one wire was pinned to the drape and using the alternate wire, a 9-french side-arm sheath was advanced down into the left axillary vein.  the dilator and wire were removed.  a defibrillation lead was then advanced down into the atrium.  the peel-away sheath was removed.  the lead was then passed across the tricuspid valve and positioned in the apical septal location.  the active fix screw was deployed.  adequate pacing and sensing functions were established.  a 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  the suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  using the wire that had been pinned to the drape, a 7-french side-arm sheath was advanced over this wire into the axillary vein.  the wire and dilator were removed.  an active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  the lead was parked until a later time.  using the separate access point, a 9-french side-arm sheath was advanced into the left axillary vein.  the dilator and wire were removed.  a curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  the coronary sinus was cannulated.  inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  a coronary sinus venogram was then performed.  it was noted that the most suitable location for lead placement was the middle cardiac vein.  this was cannulated and a passive lead was advanced over a whisper eds wire into a distal position.  adequate pacing and sensing functions were established.  a 10-volt pacing was used temporarily.  there was no diaphragmatic stimulation.  the outer sheath was peeled away.  the 9 french sheath was then peeled away.  suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  at this point, the atrial lead was then positioned in the right atrial appendage using a preformed j-curved stylet.  the lead body was turned several times and the lead was affixed to the tissue.  adequate pacing and sensing function were established.  a suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  the pocket was then washed with antibiotic-impregnated saline.  pulse generator was obtained and connected securely to the leads.  the leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch.  sponge and needle counts were correct at the end of the procedure and no acute complications were noted. the patient was sedated further and shock on t was performed on two separate occasions.  the device was allowed to detect the charge and defibrillate, establishing the entire workings of the icd system. device data1.  pulse generator, manufacturer boston scientific, model # n119, serial #12345.2.  right atrial lead, manufacturer guidant, model #4470, serial #12345.3.  right ventricular lead, manufacturer guidant, model #0185, serial #12345.4.  left ventricular lead, manufacturer guidant, model #4549, serial #12345. measured intraoperative data1.  right atrial lead impedance 705 ohms.  p-waves measured at 1.7 millivolts.  pacing threshold 0.5 volt at 0.4 milliseconds.2.  right ventricular lead impedance 685 ohms.  r-waves measured 10.5 millivolts.  pacing threshold 0.6 volt at 0.4 milliseconds.3.  left ventricular lead impedance 1098 ohms.  r-waves measured 5.2 millivolts.  pacing threshold 1.4 volts at 0.4 milliseconds. defibrillation threshold testing1.  shock on t.  charge time 2.9 seconds.  energy delivered 17 joules, successful with lead impedance of 39 ohms.2.  shock on t.  charge time 2.8 seconds.  energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms. device settings1.  a pacing ddd 60 to 120.2.  vt-1 zone 165 beats per minute.  vt-2 zone 185 beats per minute.  vf zone 205 beats per minute. conclusions1.  successful implantation of a biventricular automatic implantable cardiovascular defibrillator2.  defibrillation threshold of less than or equal to 17.5 joules.2.  no acute complications. plan1.  the patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.2.  chest x-ray to rule out pneumothorax and verified lead position.3.  device interrogation in the morning.4.  completion of the course of antibiotics.5.  home dismissal instructions provided in written format.6.  wound check in 7 to 10 days.7.  enrollment in device clinic."
+"exam:  ct abdomen and pelvis with contrast  reason for exam: nausea, vomiting, diarrhea for one day.  fever.  right upper quadrant pain for one day.   comparison:  none.  technique:  ct of the abdomen and pelvis performed without and with approximately 54 ml isovue 300 contrast enhancement.   ct abdomen:  lung bases are clear.  the liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  the aorta is normal in caliber.  there is no retroperitoneal lymphadenopathy.   ct pelvis:  the appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  per ct, the colon and small bowel are unremarkable.  the bladder is distended.  no free fluid/air.  visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation. impression:1.  unremarkable exam; specifically no evidence for acute appendicitis. 2.  no acute nephro-/ureterolithiasis. 3.  no secondary evidence for acute cholecystitis. results were communicated to the er at the time of dictation."
+"reason for consultation:  congestive heart failure. history of present illness:  the patient is a 75-year-old gentleman presented through the emergency room.  symptoms are of shortness of breath, fatigue, and tiredness.  main complaints are right-sided and abdominal pain.  initial blood test in the emergency room showed elevated bnp suggestive of congestive heart failure.  given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  incidentally, his x-ray confirms pneumonia. coronary risk factors:  history of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive. family history:  positive for coronary artery disease. past surgical history:  the patient denies any major surgeries. medications:  aspirin, coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d. allergies:  none reported. personal history:  married, active smoker, does not consume alcohol.  no history of recreational drug use. past medical history:  hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, copd, and presentation as above.  the patient is on anticoagulation on coumadin, the patient does not recall the reason. review of systems:constitutional:  weakness, fatigue, and tiredness.heent:  history of blurry vision and hearing impaired.  no glaucoma.cardiovascular:  shortness of breath, congestive heart failure, and arrhythmia.  prior history of chest pain.respiratory:  bronchitis and pneumonia.  no valley fever.gastrointestinal:  no nausea, vomiting, hematemesis, melena, or abdominal pain.urological:  no frequency or urgency.musculoskeletal:  no arthritis or muscle weakness.skin:  non-significant.neurological:  no tia.  no cva or seizure disorder.endocrine:  non-significant.hematological:  non-significant.psychological:  anxiety.  no depression. physical examination:vital signs:  pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.heent:  atraumatic and normocephalic.neck:  supple.  neck veins flat.lungs:  air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.heart:  pmi displaced.  s1 and s2, regular.  systolic murmur.abdomen:  soft and nontender.extremities:  trace edema of the ankle.  pulses are feebly palpable.  clubbing plus.  no cyanosis.cns:  grossly intact.musculoskeletal:  arthritic changes.psychological:  normal affect. laboratory and diagnostic data:  ekg shows sinus bradycardia, intraventricular conduction defect.  nonspecific st-t changes. laboratories noted with h&#038;h 10/32 and white count of 7.  inr 1.8.  bun and creatinine within normal limits.  cardiac enzyme profile first set 0.04, bnp of 10,000. nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect. impression:  the patient is a 75-year-old gentleman admitted for:1.  pneumonia, chest x-ray confirms the same with shortness of breath.2.  ischemic cardiomyopathy with abnormal stress test, inferior defect, ejection fraction 39% with elevated bnp, possibly secondary to underlying infection versus decompensated congestive heart failure.3.  smoking history, hypertension, and hyperlipidemia.4.  anticoagulation with coumadin. recommendations:from cardiac standpoint, the patient will be aggressively treated for pneumonia.  once the pneumonia is resolved and fever is under control, consideration will be given for cardiac workup.  all the questions were discussed in this regard.  the patient understood aggressive plan of care."
+"procedure:  left heart catheterization, coronary angiography, left ventriculography. complications:  none. procedure detail:  the right femoral area was draped and prepped in the usual fashion after xylocaine infiltration.  a 6-french arterial sheath was placed in the usual fashion.  left and right coronary angiograms were then performed in various projections after heparin was given 2000 units intraaortic.  the right coronary artery was difficult to cannulate because of its high anterior takeoff.  this was nondominant.  several catheters were used.  ultimately, an al1 diagnostic catheter was used.  a pigtail catheter was advanced across the aortic valve.  left ventriculogram was then done in the rao view using 30 ml of contrast.  pullback gradient was obtained across the aortic valve.  femoral angiogram was performed through the sheath which was above the bifurcation, was removed with a perclose device with good results.  there were no complications.  he tolerated this procedure well and returned to his room in good condition. findings1.  right coronary artery:  this has an unusual high anterior takeoff.  the vessel is nondominant, has diffuse mild-to-moderate disease.2.  left main trunk:  a 30% to 40% distal narrowing is present.3.  left anterior descending:  just at the ostium of the vessel and up to and including the bifurcation of the first large diagonal branch, there is 80 to 90% narrowing.  the diagonal is a large vessel about 3 mm in size.4.  circumflex:  dominant vessel, 50% narrowing at the origin of the obtuse marginal.  after this, there is 40% narrowing in the av trunk.  the small posterior lateral branch has diffuse mild disease and then the vessel gives rise to a fairly large posterior ventricular branch, which has 70% ostial narrowing, and then after this the posterior descending has 80% narrowing at its origin.5.  left ventriculogram:  normal volume in diastole and systole.  normal systolic function is present.  there is no mitral insufficiency or left ventricular outflow obstruction. diagnoses1.  severe complex left anterior descending and distal circumflex disease with borderline, probably moderate narrowing of a large obtuse marginal branch.  dominant circumflex system.  severe disease of the posterior descending.  mild left main trunk disease.2.  normal left ventricular systolic function. given the complex anatomy of the predominant problem which is the left anterior descending; given its ostial stenosis and involvement of the bifurcation of the diagonal, would recommend coronary bypass surgery.  the patient also has severe disease of the circumflex which is dominant.  this anatomy is not appropriate for percutaneous intervention.  the case will be reviewed with a cardiac surgeon."
+"<strong>reason for referral:</strong> the patient is a 58-year-old african-american right-handed female with 16 years of education who was referred for a neuropsychological evaluation by dr. x. she is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the &#8220;early stages of a likely dementia&#8221; and was thereafter terminated from her position as a psychiatric nurse. a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning. the patient was fully informed about the nature of this evaluation and intended use of the results. <strong>relevant background information: </strong>historical information was obtained from a review of available medical records and clinical interview with the patient. a summary of pertinent information is presented below. please refer to the patient&#8217;s medical chart for a more complete history. <strong>history of presenting problem:</strong> the patient reported that she had worked as a nurse supervisor for hospital center for four years. she was dismissed from this position in september 2009, although she said that she is still under active status technically, but is not able to work. she continues to receive some compensation through fmla hours. she said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from state services. she said that these 90 days are up around the end of november. she said the reason for her dismissal was performance complaints. she said that they began &#8220;as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor&#8217;s note for any days off. she said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays. she described it as a very chaotic and hectic work environment in which she was often putting in extra time. she said that since september 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback. in july of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time. following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, dr. y, ph.d. he completed a comprehensive independent medical evaluation on 08/14/2009. she said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore. please note that we do not have copies of any of her work-related correspondence. the patient never received a copy of the neuropsychological evaluation because she was told that it was &#8220;too derogatory.&#8221; a copy of that evaluation was provided directly to this examiner for the purpose of this evaluation. to summarize, the results indicated &#8220;diagnostically, the patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history. this suggests that her intellectual functioning has declined.&#8221; it concluded that &#8220;results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy������� the patient&#8217; deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing. the prognosis for improvement is not good, although she might try stimulant medication if compatible with her other. following her dismissal, the patient presented to her primary physician, henry fein, m.d., who referred her to dr. x for a second opinion regarding her cognitive deficits. his neurological examination on 09/23/2009 was unremarkable. the patient scored 20/30 on the mini-mental status exam missing one out of three words on recall, but was able to do so with prompting. a repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure. <strong>imaging studies: </strong>mri of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions. note that the mri was done with and without gadolinium contrast. <strong>current functioning: </strong>the patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her. when asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills. she also denied any problems with attention and concentration or forgetfulness or memory problems. she continues to independently perform all activities of daily living. she is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning. she reported that if her children had noticed anything they definitely would have brought it to her attention. she said that she does not currently have a lawyer and does not intend to return to her previous physician. she said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application. other current symptoms include excessive fatigue. she reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia. she also reported having fallen approximately five times within the past year. she said that this typically occurs when she is climbing up steps and is usually related to her right foot &#8220;like dragging.&#8221; dr. x&#8217;s physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis. she said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body. muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip. <strong>other medical history: </strong>the patient reported that her birth and development were normal. she denied any significant medical conditions during childhood. as mentioned, she now has a history of fibromyalgia. she also experiences some restriction in the range of motion with her right arm. mri of the c-spine 04/02/2009 showed a hemangioma versus degenerative changes at c7 vertebral body and bulging annulus with small central disc protrusion at c6-c7. mri of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon. as mentioned, she was diagnosed with chronic fatigue syndrome in 1991. she thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control. she also has diabetes, high blood pressure, osteoarthritis, tension headaches, gerd, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974. her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007. she has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night. she did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep. <strong>current medications:</strong> novolog, insulin pump, metformin, metoprolol, amlodipine, topamax, lortab, tramadol, amitriptyline, calcium plus vitamin d, fluoxetine, pantoprazole, naprosyn, fluticasone propionate, and vitamin c. <strong>substance use: </strong>the patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs. she drinks two to four cups of coffee per day. <strong>social history: </strong>the patient was born and raised in north carolina. she was the sixth of nine siblings. her father was a chef. he completed third grade and died at 60 due to complications of diabetes. her mother is 93 years old. her last job was as a janitor. she completed fourth grade. she reported that she has no cognitive problems at this time. family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. the patient completed a bachelor of science in nursing through state university in 1979. she denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. she was married for two years. her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. she has two children ages 43 and 30. her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in new york. in school, the patient reported obtaining primarily a&#8217;s and b&#8217;s. she said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. the patient worked for hospital center for four years. prior to that, she worked for an outpatient mental health center for 2-1/2 years. she was reportedly either terminated or laid off and was unsure of the reason for that. prior to that, she worked for walter p. carter center reportedly for 21 years. she has also worked as an ob nurse in the past. she reported that other than the two instances reported above, she had never been terminated or fired from a job. in her spare time, the patient enjoys reading, participating in women&#8217;s groups doing puzzles, playing computer games. <strong>psychiatric history: </strong>the patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. she was also taking prozac during that time. she then began taking prozac again when she started working at secondary to stress with the work situation. she reported a chronic history of mild sadness or depression, which was relatively stable. when asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. she denied any history of suicidal ideation or homicidal ideation. <strong>tasks administered:</strong> clinical interview adult history questionnaire wechsler test of adult reading (wtar) mini mental status exam (mmse) cognistat neurobehavioral cognitive status examination repeatable battery for the assessment of neuropsychological status (rbans; form xx) mattis dementia rating scale, 2nd edition (drs-2) neuropsychological assessment battery (nab) wechsler adult intelligence scale, third edition (wais-iii) wechsler adult intelligence scale, fourth edition (wais-iv) wechsler abbreviated scale of intelligence (wasi) test of variables of attention (tova) auditory consonant trigrams (act) paced auditory serial addition test (pasat) ruff 2 &amp; 7 selective attention test symbol digit modalities test (sdmt) multilingual aphasia examination, second edition (mae-ii) token test sentence repetition visual naming controlled oral word association spelling test aural comprehension reading comprehension boston naming test, second edition (bnt-2) animal naming test controlled oral word association test (cowat: f-a-s) the beery-buktenica developmental test of visual-motor integration (vmi) the beery-buktenica developmental test of motor coordination the beery-buktenica developmental test of visual perception hooper visual organization test (vot) judgment of line orientation (jolo) rey complex figure test (rcft) wechsler memory scale, third edition (wms-iii) wechsler memory scale, fourth edition (wms-iv) california verbal learning test, second edition (cvlt-ii) rey auditory-verbal learning test (ravlt) delis-kaplan executive function system (d-kefs) trail making test verbal fluency (letter &amp; category) design fluency color-word interference test tower wisconsin card sorting test (wcst) stroop color-word test color trails trail making test a &amp; b wide range achievement test, fourth edition (wrat-iv) woodcock johnson tests of achievement, third edition (wj-iii) nelson-denny reading test grooved pegboard purdue pegboard finger tapping test beck depression inventory (bdi) mood assessment scale (mas) state-trait anxiety inventory (stai) minnesota multiphasic personality inventory, second edition (mmpi-2) millon clinical multiaxial inventory, third edition (mcmi-iii) millon behavioral medicine diagnostic (mbmd) behavior rating inventory of executive function (brief) adaptive behavior assessment system, second edition (abas-ii) <strong>behavioral observations:</strong> the patient arrived unaccompanied and on time for her appointment. she ambulated independently and no gross psychomotor abnormalities were noted. vision and hearing appeared to be adequate for testing. she was neatly dressed and groomed. eye contact was good. she was oriented to person, place, time, and situation. speech was mildly slow and a few mild articulatory errors were noted near the end of the day, and a few paraphasic errors were noted on a confrontation naming task. there were otherwise no apparent problems with expression and speech was normal with respect to rhythm and prosody. she was somewhat quiet, but quite cooperative throughout the day. affect appeared to be mildly constricted, but she smiled and joked appropriately at times. mood appeared to be euthymic. receptive language abilities appeared to be within broad normal limits as she was able to appropriately respond to the examiner&#8217;s questions and instructions. thought processes were linear and goal-directed and no thought disturbances were noted. she appeared quite tired near the end of the day and it should be noted that sustained attention task was the last test that was given at the end of the day. when asked, the patient said that she recognized some of the tests that were given, but not most of them. she denied having look up any information on any of the tests that are typically involved in a neuropsychological battery or having any additional information about them since her last testing. overall, the patient appeared to put full effort into this evaluation. she was highly motivated and thus these results should be seen as an accurate reflection of her current cognitive functioning. note that there was some overlap in tests that were administered during this evaluation and those given at her evaluation in august of 2009. these include the ways for cpt ii, verbal fluency, and boston naming test, but this exception of the ways for most of these tests are not expected to have a significant practice effect associated with them; however, they will be interpreted with her recent evaluation in mind. <strong>evaluation findings:</strong> classification level |&#8211;| percentile rank |&#8211;| standard score |&#8211;| scaled score |&#8211;| t-score very superior |&#8212;&#8211;| &gt; 98 |&#8212;&#8211;| &gt;130 |&#8212;&#8211;| &gt; 16 |&#8212;&#8211;| &gt; 70 superior |&#8212;&#8211;| 91-97 |&#8212;&#8211;| 120-129 |&#8212;&#8211;| 14-15 |&#8212;&#8211;| 64-69 high average |&#8212;&#8211;| 75-90 |&#8212;&#8211;| 110-119 |&#8212;&#8211;| 12-13 |&#8212;&#8211;| 57-63 average |&#8212;&#8211;| 25-74 |&#8212;&#8211;| 90-109 |&#8212;&#8211;| 8-11 |&#8212;&#8211;| 44-56 low average |&#8212;&#8211;| 9-24 |&#8212;&#8211;| 80-89 |&#8212;&#8211;| 6-7 |&#8212;&#8211;| 37-43 borderline |&#8212;&#8211;| 2-8 |&#8212;&#8211;| 68-79 |&#8212;&#8211;| 4-5 |&#8212;&#8211;| 29-36 impaired |&#8212;&#8211;| &lt; 1 |&#8212;&#8211;| &lt; 67 |&#8212;&#8211;| 1-3 |&#8212;&#8211;| &lt; 28 <strong>general cognitive ability: </strong>the patient performed in the high average range on a measure of gross cognitive functioning. her performances were within expected limits across subtests assessing attention, initiation, visuospatial construction, conceptualization, and memory. <strong>intellectual functioning: </strong>based on a word reading test, premorbid intellectual functioning was estimated to fall in the average range. current intellectual functioning fell in the average range (full scale iq equals 98, 45th percentile). her index scores also indicated average performance across tasks assessing the verbal knowledge and comprehension, visuospatial perception and reasoning, working memory (i.e. complex attention) and information processing. significant relative strengths were seen on tasks assessing stored verbal knowledge and nonverbal reasoning. significant relative weaknesses were seen on task assessing visuospatial perception and construction that included a time demand (low average). compared to her previous test results, the pattern of findings is quite similar with stronger performance on verbal relative to nonverbal tasks or those with significant working memory or speed demands. however, she performed somewhat better on most of these tasks in the current evaluation. to some degree this likely reflects measurement error and variability in addition to some practice effects, although some tests are less susceptible to such changes relative to others. <strong>academic achievement: </strong>the patient performed within the average range across tasks assessing word reading, sentence comprehension, and spelling skills. her previous evaluation referred to a number of misspellings that she had made on her list of medications and certain medical conditions and she made consistent errors again during this evaluation suggesting that she may simply have a weakness in this area. <strong>attention: </strong>auditory working memory was within the average range. visual working memory was low average. on a selective visual attention test, she demonstrated good accuracy in finding target stimuli while scanning information, although her overall speed was in the low average range. on a continuous performance test assessing sustained attention, she also demonstrated good accuracy, although it was noted that her response time tended to be slower when stimuli were presented with a longer interstimulus interval suggesting some difficulty adapting to changes in the temporal stimulus presentation. note that this latter performance is entirely consistent with her previous results and taken together these results suggest that attentional abilities were generally within expectations with some mildly weaker performance for complex visual relative to verbal information. there were inconsistencies noted in attentional abilities for both verbal and visual working memory. <strong>information processing speed: </strong>as noted, the patient had some difficulty adapting to changes in stimulus presentation speed on sustained attention task and there was some suggestion in her performances that she reduced her speed in order to increase accuracy; however, basic visual scanning and sequencing and psychomotor processing were in the average to high average range. <strong>language: </strong>mild articulatory and paraphasic errors were noted on a confrontation naming test. verbal retrieval for phonemic or category cues were in the high average and average range respectively. stored verbal knowledge was in the average range with as mentioned strengths noted in vocabulary. those language abilities were generally within expected limits. <strong>visuospatial perception and construction: </strong>the patient demonstrated variability in her performances on tasks assessing visuospatial perception and construction. basic visual perception assessed through her ability to accurately interpret angular line orientations was in the high average. mental organization and synthesis of parts of visual figures was in the average range on an untimed task that involved namable objects and in the low average range and relative weakness when it involved timed synthesis of shapes. visuospatial construction using either line drawings or blocks to match to a sample design was in the borderline to low average range. thus taken together, the patient demonstrated some relative weaknesses in aspects of visuospatial processing, particularly when tasks involved the time component or shapes and figures rather than recognizable objects. <strong>learning &amp; memory skills:</strong> <strong>verbal learning and memory:</strong> initial acquisition of a list of 15 unrelated items within the high average range (she successfully recalled eight items). she benefited significantly from repetition and demonstrated immediate and significant improvement in her recall, although across five learning trials, her learning curve was mildly inconsistent suggesting attentional weaknesses; however, following the fifth trial, her overall learning fell in the superior range (all 15 items were successfully recalled). spontaneous recall following a 20-minute delay was in the average range as she was able to remember 11 of the 15 items. she correctly recognized all those items during recognition (high average). taking together these memory results are well within expected limits. she demonstrated some mild forgetting, but still fell within the average range and was able to recognize items effectively suggesting mild weaknesses and inconsistencies with retrieval and attentional weaknesses may have contributed to variability in her learning curve initially. <strong>visual learning and memory: </strong>the patient&#8217; immediate recall of a complex figure was in the average range. she retained all of that information following a delay and her recall was in the high average range. recognition of the individual components of the figure was impaired. taken together these results highlight some difficulties with complex visuospatial perception and construction, although memory per se was intact based on her very strong recall performances. note also that she demonstrated this strong memory despite some initial errors in her copy of the complex figure itself again highlighting difficulties with perception and construction, but good overall memory functioning. <strong>executive functioning: </strong>as mentioned, working memory was stronger for verbal than visual information, but both were within broad normal limits. verbal fluency was within expected limits as well and she demonstrated particular strength in switching between semantic categories (very superior). design fluency was average. cognitive set shifting, inhibition of prepotent responses and planning and problem solving all fell within the average to high average range and within expected limits. abstract reasoning for visual and verbal information was also good. thus taken together, the patient did not demonstrate any difficulties with tasks assessing executive functioning. <strong>motor functioning:</strong> fine motor coordination skills were within the average range with both her right dominant hand and left hand. strength was impaired on both sides while basic motor speed was in the borderline range for both hands. these results are very similar to those that were found in her previous evaluation. they are consistent with decreased strength, but no loss of dexterity and they do not suggest any lateralized deficits. <strong>emotional functioning: </strong>on an affective screening measure, the patient endorsed only three items suggesting reduced energy and reduced clarity of thinking. overall, these results suggest that she is not experiencing clinically significant depressive symptoms at this time. <strong>summary &amp; impressions: </strong>this is a 58-year-old african-american female with 16 years of education who is referred for a neuropsychological evaluation by dr. x in order to assess for possible cognitive impairment. she reported that she had recently been terminated from her position as a supervisory nurse in a psychiatric hospital following a neuropsychological evaluation that concluded that she may be in the &#8220;early stages of a likely dementia&#8221;. this evaluation was requested as a second opinion in order to clarify the nature of her cognitive impairment and make recommendations for ongoing treatment planning. overall, intellectual functioning fell in the average range on this evaluation. note that the same battery of tests was used in order to assess intellectual functioning and given the recency of her previous evaluation to some degree practice effects may have impacted her performance. however, we would not expect as significant of an impact upon tasks assessing processing speed and working memory. the same pattern of performance was noted across subtests in the intellectual battery with stronger performance on verbal knowledge based tasks relative to those assessing processing speed, working memory, and visuospatial skills. however, during this evaluation, she demonstrated significant improvement across tasks so that in general her profile is elevated, but the same profile pattern was seen. note that along with practice effects, performance can also be impacted by changes in attention, as well as measurement error. the possibility of attentional fluctuations having contributed to some of her performance is a definite possibility based on her performance on some attention tasks, which suggested that she at times performed better and was able to sequence in mind more information than she was able to passively repeat and she demonstrated inconsistencies in her learning curve on the memory task. our assessment of her intelligence as falling within the average range is consistent with our estimate of premorbid intellectual functioning and educational and occupational history. note that the ways for technical manual indicates that test retest gains are less pronounced for verbal comprehension and working memory subtests than perceptual reasoning and processing speed subtests and the patient&#8217; improvements were much higher than the mean increases in the normative sample that averaged a shorter period between testing and retesting. this suggests that as noted above other factors were applied, perhaps including attentional fluctuations. relative to intellectual functioning, the patient performed within expected limits across tasks assessing language functioning, verbal and visual memory, and executive skills and sustained attention. variability in performances was seen for information processing speed, particularly when responding to changes in the tempo of stimulus presentation or making more complex visual discriminations. immediate attention was also somewhat variable as she should be able to mentally manipulate greater amounts of visual and verbal material and she could just passively replicate. the better performance on raw scores on these more complex tasks is unusual and suggests fluctuations in attention for reasons other than brain base deficits. she also demonstrated weaker skills in complex visuospatial processing, particularly for shapes and figures rather than recognizable objects. of note, she performed poorly when these tasks involved the time component. meteorically, she demonstrated bilateral impairments in strength and motor speed, but dexterity and fine motor manipulation skills were within expected limits. the lack of lateralizing information and motor skills suggests that more peripheral factors and pain may have contributed to these results. taken together, these results do not necessarily suggest that there has been any significant decline from premorbid levels. it is possible that the patient has always had weaknesses in visuospatial processing and note that these weaknesses were not in basic visual skills and processing skills, but rather in putting together shapes and figures. the inconsistencies in her performances on processing speed and attention tasks suggest that while she may be somewhat slowed in completing tasks, there may be contributors other than brain base changes that impacted her results. in particular, the patient&#8217; current medications, as well as pain, fatigue, and medical conditions such as diabetes and associated possible neuropathy are likely important factors. results do not suggest the presence of a progressive dementing disorder. given the multiple factors that may have contributed to some of our findings, we do not believe that any cognitive disorder should be diagnosed at this time. if there are significant concerns about her cognitive functioning, it may be useful to make adjustments in her medication regimen. this is a not a work based evaluation and therefore questions regarding her ability to perform job duties will not be addressed. one concern that we would like to bring up is that if visuospatial problems are of newer onset, they may be contributing to her recent falls and thus should be monitored for changes and progression and she should return for reevaluation in one year&#8217;s time in order to determine any changes in her cognitive functioning. additional recommendations are provided below. note that there was a little overlap in tests given between the two testing sessions aside from the ways for cpt to word fluency. also note that she completed the brief self-report instrument and all of her results fell within normal limits. <strong>recommendations:</strong> 1. based on fluctuations in processing speed and attention, it is possible that the patient&#8217; current medications may be impacting her cognitive functioning to some degree. decisions regarding any changes are deferred to her physicians, but it may be useful to streamline her current medications while also continuing to effectively address symptoms. 2. the patient should return for reevaluation in one year&#8217;s time to monitor her cognitive functioning and evaluate for any improvements in performance following any medication changes. note also that stress related to her work situation and the nature of her previous neuropsychological evaluation may have also contributed to some of her difficulties on that testing. 3. the nature of her frequent falls is uncertain, but it is possible that weaknesses in visuospatial processing may be contributing and this should be further evaluated by her physicians."
+"history of present illness:  this is a 41-year-old registered nurse (r.n.).  she was admitted following an overdose of citalopram and warfarin.  the patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  she notes starting in january, her husband of five years seemed to be quite withdrawn.  it turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  the patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  they had moved to abcd where he had recently been employed as a restaurant manager.  she also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  she has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  in january, she went on citalopram.  she reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood. past and developmental history:  she was born in xyz.  she describes the family as being somewhat dysfunctional.  father was a truckdriver.  she is an only child.  she reports that she had a history of anorexia and bulimia as a teenager.  in her 20s, she served six years in naval reserve.  she was previously married for four years.  she described that as an abusive relationship.  she had a history of being in counseling with abc, but does not think this therapist, who is now by her estimate 80 years old, is still in practice. physical examination:  general:  this is an alert and cooperative woman.vital signs:  temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.psychiatric:  she makes good eye contact.  speech is normal in rate, volume, grammar, and vocabulary.  there is no thought disorder.  she denies being suicidal.  her affect is appropriate for material being discussed.  she has a sense of future, wants to get back to work, has plans to return to counseling.  she appeared to have normal orientation, concentration, memory, and judgment. medical history is notable for factor v leiden deficiency, history of pulmonary embolus, restless legs syndrome.  she has been off her mirapex.  i did encourage her to go back on the mirapex, which would likely lead to some improvement in mood by facilitating better sleep. the patient at this time can contract for safety.  she has made plans for outpatient counseling this saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with. laboratory data:  inr, which is still 8.8.  in 1998, she had a normal mri.  electrolytes, bun, creatinine, and cbc were all normal. diagnoses:  1.  seasonal depressive disorder.2.  restless legs syndrome.3.  overdose of citalopram and warfarin. recommendations:  the patient reports she has been feeling better since discontinuing antidepressants.  i, therefore, recommend she stay off antidepressants at present.  if needed, she can take prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  she does give a fairly good history of seasonal depression and given that her mood has improved in the past with prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling. please feel free to contact me at digital pager if there is additional information i can provide."
+"name of procedure1.  left heart catheterization with left ventriculography and selective coronary angiography.2.  percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery. history:  this is a 58-year-old male who presented with atypical chest discomfort.  the patient had elevated troponins which were suggestive of a myocardial infarction.  the patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization. procedure details:  informed consent was given prior to the patient was brought to the catheterization laboratory.  the patient was brought to the catheterization laboratory in postabsorptive state.  the patient was prepped and draped in the usual sterile fashion, 2% xylocaine solution was used to anesthetize the right femoral region.  using modified seldinger technique, a 6-french arterial sheath was placed.  then, the patient had already been on heparin.  then, a judkins left 4 catheter was intubated into the left main coronary artery.  several projections were obtained and the catheter was removed.  a 3drc catheter was intubated into the right coronary artery.  several projections were obtained and the catheter was removed.  then, a 3drc guiding catheter was intubated into the right coronary artery.  then, a universal wire was advanced across the lesion into the distal right coronary artery.  integrilin was given.  then, a 3.0 x 12 voyager balloon was inflated at 13 atmospheres for 30 seconds.  then, a projection was obtained.  then, a 3.0 x 15 vision stent was placed into the distal right coronary artery.  the stent was deployed at 15 atmospheres for 25 seconds.  post stent, the patient was given intracoronary nitroglycerin after one projection.  then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  then, a pilot 150 wire was advanced across the lesion.  then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  however, it was felt that there was adequate flow and no further intervention needed to be performed.  then, the stent delivery system was removed.  a pigtail catheter was placed into the left ventricle.  hemodynamics followed by left ventriculography was performed.  then, a pullback gradient was performed and the catheter was removed.  then, the right femoral artery was visualized and using angiography and then an angio-seal was applied.  the patient was transferred back to his room in good condition. findings1.  hemodynamics:  the opening aortic pressure was 116/61 with a mean of 64.  the opening left ventricular pressure was 112 with end-diastolic pressure of 23.  lv pressure on pullback was 106 with end-diastolic pressure of 21.  aortic pressure was 111/67 with a mean of 87.  the closing pressure was 110/67.2.  left ventriculography:  the left ventricle was of normal cavity, size, and wall thickness.  there is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  the overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  the mitral valve had no significant prolapse or regurgitation.  the aortic valve appeared to be trileaflet and moved normally.3.  coronary angiography:  the left main is a normal-caliber vessel.  this bifurcates into the left anterior descending and circumflex arteries.  the left main is free of any significant obstructive coronary artery disease.  the left anterior descending is a large vessel that extends to the apex.  it gives off approximately 10 septal perforators and 5 diagonal branches.  the first diagonal branch was large.  the left anterior descending had mild irregularities, but no high-grade disease.  the left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  the two obtuse marginal branches are large.  there is a relatively small left atrial branch.  the left circumflex had a 50% stenosis after the first obtuse marginal branch.  the rest of the vessel is moderately irregular, but no high-grade disease.  the right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  the right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  however, distal between the second and third posterolateral branch, there is a 90% stenosis.  the rest of the vessels had mild irregularities, but no high-grade disease.  then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  then, a wire was advanced through this and there was improvement of flow.  there is improvement from timi grade 2 to timi grade 3 flow. clinical impression1.  successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.2.  two-vessel coronary artery disease.3.  elevated left ventricular end-diastolic pressure.4.  mild anterolateral and moderate inferoapical hypokinesis. recommendations1.  integrilin.2.  bed rest.3.  risk factor modification.4.  thallium scintigraphy in approximately six weeks."