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OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating room table. The patient was prepped and draped in usual sterile fashion. An incision was made in the groin crease overlying the internal ring. This incision was about 1.5 cm in length. The incision was carried down through the Scarpa's layer to the level of the external oblique. This was opened along the direction of its fibers and carried down along the external spermatic fascia. The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free. A hernia sac was identified and the testicle was located. Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring. This was performed by incising the transversalis fascia circumferentially. The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity. Care was taken not to injure the testicular vessels. Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance. The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high. This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum. The testicle was viable. This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum. A small 1 cm incision was made in the anterior superior scrotal wall. Dissection was carried down through the dartos layer. A subdartos pouch was formed with blunt dissection. The hemostat was then pushed against the tissues and this tissue was divided. The hemostat was then passed through the incision. A Crile hemostat was passed back up into the inguinal canal. The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision. The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle. The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture. Benzoin and a Steri-Strip were placed. Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly. This was done with 2 to 3 interrupted 3-0 silk sutures. The external oblique was then closed with interrupted 3-0 silk suture. The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch. Benzoin and Steri-Strip were applied. The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.surgery, orchiopexy, benzoin, crile hemostat, scarpa's layer, caudal block, cremasteric fascia, groin crease, hemiscrotum, iliopubic tract, inguinal canal, inguinal herniorrhaphy, intracuticular stitch, retroperitoneum, spermatic fascia, testicle, hernia sac, inguinal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

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

EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear

CHIEF COMPLAINT:, The patient comes for her first Pap smear, complaining of irregular periods.,HISTORY OF PRESENT ILLNESS:, The patient wishes to discuss considering something to help with her menstrual cramping and irregular periods. She notes that her periods are out of weck. She says that she has cramping and pain before her period starts. Sometimes, she is off her period for two weeks and then she bleeds for two whole weeks. She usually has her periods lasting seven days, usually comes on the 19th of each month and now it seems to have changed. The cramping is worse. She said her flow has increased. She has to change her pad every half to one hour and uses a super tampon sometimes. She usually has four days of hard flow and then she might have 10 days where she will have to wear a mini pad. She also notes that her headaches have been worsening a little bit. She has had quite a bit of stress. She had a headache on Wednesday again after having had one on the weekend. She said she usually only has an occasional headache and that is not too bad but now she has developed what she would consider to be a migraine and she has not had serious headaches like this and it seems to be worsening and coming a little bit more regularly, and she has not figure out what to do to get rid of them. She avoids caffeine. She only eats chocolate when she is near her period and she usually drinks one can of cola a day.,MEDICATIONS: , None.,ALLERGIES:, None.,SOCIAL HISTORY:, She is a nonsmoker. She is not sexually active.,PAST MEDICAL HISTORY:, She has had no surgery or chronic illnesses.,FAMILY HISTORY:, Mother has hypertension, depression. Father has had renal cysts and sometimes some stomach problems. Both of her parents have problems with their knees.,REVIEW OF SYSTEMS:, Patient denies headache or trauma. No blurred or double vision. Hearing is fine, no tinnitus or infection. Infrequent sore throat, no hoarseness or cough.,HEENT: See HPI.,Neck: No stiffness, pain or swelling.,Respiratory: No shortness of breath, cough or hemoptysis. She is a nonsmoker.,Cardiovascular: No chest pain, ankle edema, palpitations or hypertension.,GI: No nausea, vomiting, diarrhea, constipation, melena or jaundice.,GU: No dysuria, frequency, urgency or stress incontinence.,Locomotor: No weakness, joint pain, tremor or swelling.,GYN: See HPI.,Integumentary: Patient performs self-breast examinations and denies any breast masses or nipple discharge. No recent skin or hair changes.,Neuropsychiatric: Denies depression, anxiety, tearfulness or suicidal thought.,PHYSICAL EXAMINATION:,VITALS: Height 64.5 inches. Weight: 162 pounds. Blood pressure 104/72. Pulse: 72. Respirations: 16. LMP: 08/21/04. Age: 19.,HEENT: Head is normocephalic. Eyes: EOMs intact. PERRLA. Conjunctiva clear. Fundi: Discs flat, cups normal. No AV nicking, hemorrhage or exudate. Ears: TMs intact. Mouth: No lesion. Throat: No inflammation.,Neck: Full range of motion. No lymphadenopathy or thyromegaly.,Chest: Clear to auscultation and percussion.,Heart: Normal sinus rhythm, no murmur.,Integumentary: Breasts are without masses, tenderness, nipple retraction or discharge. Reviewed self-breast examination. No axillary nodes are palpable.,Abdomen: Soft. Liver, spleen, and kidneys are not palpable. No masses felt, nontender. Femoral pulses strong and equal.,Back: No CVA or spinal tenderness. No deformity noted.,Pelvic: BUS negative. Vaginal mucosa pink, scanty discharge. Cervix without lesion. Pap was taken. Uterus normal size. Adnexa: No masses. She does have some pain on palpation of the uterus.,Rectal: Good sphincter tone. No masses. Stool is guaiac negative.,Extremities: No edema. Pulses strong and equal. Reflexes are intact.,Rectal: No mass.,ASSESSMENT:, Menorrhagia, pelvic pain, dysmenorrhea, and irregular periods.,PLAN:, We will evaluate with a CBC, urinalysis and culture, and TSH. The patient has what she describes as migraine headaches of a new onset. Because of the pelvic pain, dysmenorrhea, and menorrhagia, we will also evaluate with a pelvic sonogram. We will evaluate with a CT scan of the brain with and without contrast. We will try Anaprox DS one every 12 hours for the headache. At this point, she could also use that for menstrual cramping. Prescription written for 20 tablets. If her lab findings, sonographic findings, and CT of the brain are normal, we would consider trying birth control pills to regulate her periods and reduce the cramping and excessive flow. The lab x-ray and urinalysis results will be reported to her as soon as they are available.nan

REASON FOR EXAM: ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS: ,There is an approximately 5-mm shift of the midline towards the right side. Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. There is loss of the cortical sulci on the right side. These findings are compatible with edema. Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact. The visualized paranasal sinuses are clear.,IMPRESSION: ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. A postcontrast MRI is required for further characterization of this mass. Gradient echo imaging should be obtained.neurology, numbness, head, ct images, frontal, parietal, temporal, axial ct images, parietal and temporal, ct head, slice thickness, white matter, frontal parietal, temporal lobes, parietal lobe, edema, intact, noncontrast, mass, ct, lobes, arm,

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

HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital. He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:, General nasotracheal.,COMPLICATIONS:, None.,CONDITION:, Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars. Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires. After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable. The throat pack was then removed. An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.surgery, closed reduction of mandible fractures, erich arch bars, elastic fixation, throat pack, arch bars, arch, erich, mandible, fractures

PROCEDURE:, Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. Dissection was carried down to the ulnar nerve. Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized. Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed. Meticulous hemostasis was maintained with bipolar electrocautery. The nerve was transposed anteriorly, superficial to the flexor-pronator mass. Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating. The subcutaneous tissue and skin were closed with simple interrupted sutures. Marcaine with epinephrine was injected into the wound. The elbow was dressed and splinted. The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve

PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: , Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block, size 5 mm. A NexGen tibial component, size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained.,COMPLICATIONS: ,None.,BRIEF HISTORY:, The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:, The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized, the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well. At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed, attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point, the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position, approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface. _______ was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut, take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point, this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained. At this point, the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component. At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point, to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point, all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point, the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to _______ secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point, the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition.orthopedic, knee arthroplasty, revision, zimmer nexgen, distal femoral, intramedullary guide, femoral component, femoral, knee, arthroplasty, intramedullary, patellar, medial, tibial,

CHIEF COMPLAINT:, Falls at home.,HISTORY OF PRESENT ILLNESS:, The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety. Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home. They noted that she frequently came to the emergency room for "attention." The patient denied any chest pain or pressure and no change to exercise tolerance. The patient denied any loss of consciousness or incontinence. She denies any seizure activity. She states that she "tripped" at home. Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating. They stated that she has numerous medications at home, but they were not sure if she was taking them. The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression. The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL: The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS: Stable.,HEENT: Negative.,NECK: Supple. Carotid upstrokes are 2+.,LUNGS: Clear.,HEART: Normal S1 and S2. No gallops. Rate is regular.,ABDOMEN: Soft. Positive bowel sounds. Nontender.,EXTREMITIES: No edema. There is some ecchymosis noted to the left great toe. The area is tender; however, metatarsal is nontender.,NEUROLOGICAL: Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety. Continue Paxil and Xanax use was recommended. The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1. Falls ,2. Anxiety and depression.,3. Hypertension.,4. Hypercholesterolemia.,5. Coronary artery disease.,6. Osteoarthritis.,7. Chronic obstructive pulmonary disease.,8. Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.nan

CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.nan

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's and Scarpa'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.surgery, endstage renal disease, ethibond, satinsky clamp, aponeurosis, cadaveric, cross match, curvilinear incision, hemodialysis, iliac vein, pelvic fossa, peritoneum, recipient, renal transplant, transplant, transversalis fascia, superior and inferior poles, endstage renal, renal disease, vein, electrocautery, bladder, renal, intervention,

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating. The patient at that time stated that he had established diagnosis of liver cirrhosis. Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody. Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion. He spent 3 days in the hospital. He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient. From the patient's report he was diagnosed with some kind of viral infection. At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS: Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilateral.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.,ABDOMEN: Not tender, not distended. Splenomegaly about 4 cm under the costal margin. No hepatomegaly. Bowel sounds present.,MUSCULOSKELETAL: No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC: Nonfocal. No asterixis. No costovertebral tenderness.,PSYCHE: The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63. His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53. We do not have any other results back. No hepatitis panels. No alpha-fetoprotein level. The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:, The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1. Epigastric pain. The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time. In the office twice the patient did not have any abdominal pain on physical exam. His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously. He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2. End-stage liver disease. Of course, we need to find out the cause of the liver cirrhosis. We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before. We do not have any information of any type of investigation in the past. Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X. The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result. It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level. We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver. We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B. Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C. The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also. We will need to look for nuclear antibody if it is not done before. PSC is extremely unlikely but possible. Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not. Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem. On his end-stage liver disease we already know that he had low platelet count splenomegaly. We know that his bilirubin is elevated and albumin is very low. I suspect that at the time of admission to the hospital the patient presented with encephalopathy. We do not know if INR was checked to look for coagulopathy. The patient had an EGD in 2005 as well as colonoscopy in Silver City. We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily. The patient tolerated it well; no diarrhea at this point in time. I also recommended for him to contact his primary care physician for increased dose of opiates for him. As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal. The patient got a prescription for 10 mg pills. He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58. The patient was educated how to use Inderal and he was explained why we decided to use this medication. The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues. The patient was provided information that his protein intake is supposed to be about 25 g per day. He was advised not to over-eat protein and advised not to starve. He also was advised to stay away from alcohol. His next visit is in 2 weeks with all results available.gastroenterology, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis,

PREOPERATIVE DIAGNOSIS:, Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:, General,NAME OF OPERATION:, Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:, The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. An infraumbilical incision was made, and Veress needle placed without difficulty. Gas was entered into the abdomen at two liters. The laparoscope was entered, and the abdomen was visualized. The second puncture site was made, and the second trocar placed without difficulty. The cyst was noted on the left, a 3-cm, ovarian cyst. This was needled, and a hole cut in it with the scissors. Hemostasis was intact. Instruments were removed. The patient was awakened and taken to the recovery room in good condition.surgery, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,

REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen and across the back for the last four to five days. The patient has some nausea and vomiting. The patient wants something done for the stone. The patient denies any hematuria, dysuria, burning or pain. The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY: ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time. The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Vitals are stable.,HEART: Regular rate and rhythm.,ABDOMEN: Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000. The patient's creatinine is 0.92.,ASSESSMENT:,1. Left flank pain.,2. Left ureteral stone.,3. Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow. Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed. The patient has a pretty enlarged stone. Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed. The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting. The patient understood all the risk, benefits of the procedure and wanted to proceed. Need for stent was also discussed with the patient. The patient will be scheduled for surgery tomorrow. Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.consult - history and phy., flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone,

PREOPERATIVE DIAGNOSIS:, Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1. Right thoracotomy, total decortication.,2. Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE: ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight.cardiovascular / pulmonary, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,

PREOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1. Right pelvic pain.,2. Right ovarian mass.,3. 8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED: ,Laparoscopic right salpingooophorectomy.,ANESTHESIA: ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:, None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass. Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice. Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits. There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:, The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity. The pain persisted despite multiple pain medications given in the Emergency Room. The patient reports positive nausea and vomiting. There was no vaginal bleeding or discharge. There was no fevers or chills. Her cultures done in the Emergency Room were pending. The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic. The uterus and left ovary were within normal limits. There was a positive flow noted to bilateral ovaries on ultrasound. Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:, After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty. She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion. Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above. She was prepped and draped in the usual sterile fashion. A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix. The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field. The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed. The vulsellum tenaculum was removed. The weighted speculum was removed. Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold. The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp. The CO2 was then turned on with unoccluded flow and excellent pressures. This was continued till a normal symmetrical pneumoperitoneum was obtained. Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope. Laparoscopic findings are as noted above. A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization. Then, a grasper was used to untorse the ovary. Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system. The right tube and ovary were amputated and noted to be hemostatic. The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag. The ovary was too large to fit completely into the bag. Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst. This was a clear yellow fluid. Then, the bag was closed and the ovary was removed from the suprapubic port. The suprapubic port did have to be extended somewhat to allow for the removal of the ovary. The trocar and sleeve were then placed back into the port. The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic. The pelvis was clear and clean. ,Pictures were obtained. The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6. Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed. Therefore, the peritoneal surface was noted to be hemostatic. Therefore, the camera was removed. All instruments were removed. The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed. The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6. The right flank area was palpated and there was no facial defect noted. The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion. Dressings were changed. The weighted speculum was removed from the patient's cervix. The cervix noted to be hemostatic. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.

EXAM:, Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. This most likely will affect the S1 nerve root on the left. There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. There is mild neural foraminal stenosis present. Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. There is facet sclerosis bilaterally. Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present. There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present. There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy. Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.radiology, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis,

S:, The patient is here today with his mom for several complaints. Number one, he has been having issues with his right shoulder. Approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. He has been having issues ever since. He is having difficulties raising his arm over his head. He does have some intermittent numbness in his fingers at night. He is not taking any anti-inflammatories or pain relievers. He is also complaining of a sore throat. He did have some exposure to Strep and he has a long history of strep throat. Denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. He is also being seen for ADHD by Dr. B. Adderall and Zoloft. He takes these once a day. He does notice when he does not take his medication. He is doing well in school. He is socializing well. He is maintaining his weight and tolerating the medications. However, he is having issues with anger control. He realizes when he has anger outbursts that it is a problem. His mom is concerned. He actually was willing to go to counseling and was wondering if there was anything available for him at this time.,PAST MEDICAL/SURGICAL/SOCIAL HISTORY:, Reviewed and unchanged.,O:, VSS. In general, patient is A&Ox3. NAD. Heart: RRR. Lungs: CTA. HEENT: Unremarkable. He does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. Musculoskeletal: Limited in range of motion, active on the right. He stops at about 95 degrees. No muscle weakness. Neurovascularly intact. Negative biceps tenderness. Psych: No suicidal, homicidal ideations. Answering questions appropriately. No hallucinations.soap / chart / progress notes, general medicine, adhd, attention deficit disorde, pharyngitis, anger control, anti-inflammatories, bursitis, diarrhea, fevers, nausea, numbness, rashes, shoulder, strep throat, vomiting, attention deficit, deficit disorder, anti inflammatories, soap, anger, intermittent

PREOPERATIVE DIAGNOSIS:, Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1. Medial meniscal tear, right knee.,2. Lateral meniscal tear, right knee.,3. Osteochondral lesion, medial femoral condyle, right knee.,4. Degenerative joint disease, right knee.,5. Patella grade-II chondromalacia.,6. Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1. Arthroscopy, right knee.,2. Medial meniscoplasty, right knee.,3. Lateral meniscoplasty, right knee.,4. Medial femoral chondroplasty, right knee.,5. Medical femoral microfracture, right knee.,6. Patellar chondroplasty.,7. Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:, The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position. Department of Anesthesia administered general anesthetic. Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder. Care was ensured that all bony prominences were well padded and she was positioned and secured. After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion. Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively. The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch. All compartments were then examined in sequential order with photodocumentation of each compartment. The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove. There was mild grooving of the trochlear cartilage. The medial gutter was visualized. There was no evidence of loose body. The medial compartment was then entered. There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment. There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus. The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken. At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed. This gave a smooth shoulder to the chondral lesion. After this, the meniscus was debrided until it had been smooth over the frayed edges. At this point, the shaver was removed. The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point. The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge. The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable. At this point, attention was directed to the rest of the knee. The ACL was examined. It was intact and stable. The lateral compartment was then entered. There was noted to be a grade II-III changes of the lateral femoral condyle. Again, with the edge of some friability at the shoulder of this cartilage lesion. There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus. The probe was introduced and the remaining meniscus appeared stable. This was then removed and the stapler was introduced. A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over. The lateral gutter was then visualized. There was no evidence of loose bodies. Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion. Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion. After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided. At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided. Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies. The knee was then copiously irrigated and suctioned dry. All instrumentation was removed. Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular. Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied. The patient was then transferred back to the gurney in supine position.,DISPOSITION: The patient tolerated the procedure well with no complications. The patient was transferred to PACU in satisfactory condition.

CHIEF COMPLAINT: , I need refills.,HISTORY OF PRESENT ILLNESS:, The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.,OBJECTIVE: ,Well developed and well nourished. She does not appear to be in any acute distress. Cardiovascular: Regular rhythm. No murmurs, gallops, or rubs. Capillary refill less than 3 seconds. Peripheral pulses are 2+ bilaterally. Respiratory: Her lungs are clear to auscultation bilaterally with good effort. No tenderness to palpation over chest wall. Musculoskeletal: She has full range of motion of all four extremities. No tenderness to palpation over long bones. Skin: Warm and dry. No rashes or lesions. Neuro: Alert and oriented x3. Cranial nerves II-XII are grossly intact. No focal deficits.,PLAN: , I did refill her medications. I have requested that she have her primary doctor forward her records to me. I have discussed Chantix and its use and success rate. She was given a prescription, as well as a coupon. She is to watch for any worsening signs or symptoms. She verbalized understanding of discharge instructions and prescriptions. I would like to see her back to proceed with her preventive health measures.general medicine, quit smoking, chantix, mesothelioma, smoking, xanax, refills

DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples.surgery, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,

DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture.surgery, lid speculum, conjunctival, peritomy, vitrectomy, operating, superonasally, anesthesiaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

CC:, Rapidly progressive amnesia.,HX: ,This 63 y/o RHM presented with a 1 year history of progressive anterograde amnesia. On presentation he could not remember anything from one minute to the next. He also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. He underwent extensive evaluation at the Mayo Clinic and an MRI there revealed increased signal on T2 weighted images in the mesiotemporal lobes bilaterally. There was no mass affect. The areas mildly enhanced with gadolinium.,PMH:, 1) CAD; MI x 2 (1978 and 1979). 2) PVD; s/p aortic endarterectomy (3/1991). 3)HTN. 4)Bilateral inguinal hernia repair.,FHX/SHX:, Mother died of a stroke at age 58. Father had CAD and HTN. The patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. He had been a feed salesman all of his adult life.,ROS:, Unremarkable. No history of cancer.,EXAM:, BP 136/75 HR 73 RR12 T36.6,MS: Alert but disoriented to person, place, time. He could not remember his birthdate, and continually asked the interviewer what year it was. He could not remember when he married, retired, or his grandchildren's names. He scored 18/30 on the Follutein's MMSE with severe deficits in orientation and memory. He had moderate difficulty naming. He repeated normally and had no constructional apraxia. Judgement remained good.,CN: unremarkable.,Motor: Full strength throughout with normal muscle tone and bulk.,Sensory: Intact to LT/PP/PROP,Coordination: unremarkable.,Station: No pronator drift, truncal ataxia or Romberg sign.,Gait: unremarkable.,Reflexes: 3+ throughout with downgoing plantar responses bilaterally.,Gen Exam: unremarkable.,STUDIES:, MRI Brain revealed hyperintense T2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. MRI and CT of the chest and CT of the abdomen showed no evidence of lymphadenopathy or tumor. EEG was normal awake and asleep. Antineuronal antibody screening was unremarkable. CSF studies were unremarkable and included varicella zoster, herpes zoster, HIV and HTLV testing, and cytology. The patient underwent stereotactic brain biopsy at the Mayo Clinic which showed inflammatory changes, but no organism or etiology was concluded. TFT, B12, VDRL, ESR, CRP, ANA, SPEP and Folate studies were unremarkable. Neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. Most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,IMPRESSION:, Limbic encephalitis secondary to cancer of unknown origin.,He was last seen 7/26/96. MMSE 20/30 and category fluency 20 . Disinhibited affect. Mild right grasp reflex. The clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .consult - history and phy., mri brain, progressive anterograde amnesia, retrograde memory loss, limbic encephalitis, anterograde amnesia, memory loss, limbic, encephalitis, amnesia, anterograde, memory,

PREOPERATIVE DIAGNOSIS:, Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:, Worrisome skin lesion, left hand.,PROCEDURE:, The patient gave informed consent for his procedure. After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest. There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma. A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included. The predominant portion of the biopsy was of the lesion itself.,Lesion was removed. Attention was turned toward the area. Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture. All counts were correct. The procedure was closed. A sterile dressing was applied. There were no complications. The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,surgery, skin lesion, squamous cell carcinoma, punch biopsy,

PREOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:, Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:, Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE: ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness. He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder. He was worked up by the emergency department. His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage. Oral maxillary facial surgery was consulted to manage the mandible fracture. After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures. Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital. He was laid in supine position on the operating room table. ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion. The surgeon approached the operating room table in a sterile fashion. Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion. Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior. This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth. The patient was manipulated up into maximum intercuspation. He has a malocclusion with severe bruxism and so wear facets were lined up. This was secured with 26-gauge surgical steel wire. Attention was then directed to the symphysis extraorally. Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made. Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible. The periosteum was incised and reflected with the periosteal elevator. The fracture was noted and it was displaced. Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned. This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws. The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture. Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule. After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified. It was noted that the fracture went through tooth #17 and this needed to be extracted. Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots. The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed. The fracture was noted to be well reduced. The wound was then irrigated with copious amount of sterile water. The patient was released for excellent intercuspation. He was then manipulated up into the occlusion easily. Wound was then closed with running 3-0 chromic gut suture. Attention was then directed extraorally. This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin. Attention was then again directed into the mouth. The throat pack was removed and orogastric tube was placed and stomach content was evacuated. The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions. At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.surgery, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture,

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:, Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain. He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability. He was admitted and underwent an uncomplicated surgical procedure as noted above. In the postoperative period, he was up and ambulatory. He was taking p.o. fluids and diet well. He was afebrile. His wounds were healing well. Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP: ,At this time, the patient will follow up with me in the office in six weeks' time. The patient understands discharge plans and is in agreement with the discharge plan. He will follow up as noteddischarge summary, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg

SUBJECTIVE: ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT: Denies any severe headache or sore throat.,CHEST: No true pain.,GI: No nausea, vomiting, or diarrhea.,PAST HISTORY:, He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation. He also lists some other medications. I do have his medications list. He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines. Those are the predominant medicines. He is not a diabetic. The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema. No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL: The patient appears comfortable. He did not appear to be in any respiratory distress. He was alert. I heard him cough once during the entire encounter. He did not bring up any sputum at that time.,VITAL SIGNS: His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT: Throat was normal.,RESPIRATORY: He was breathing normally. There was clear and equal breath sounds. He was speaking in full sentences. There was no accessory muscle use.,HEART: Sounded regular.,SKIN: Normal color, warm and dry.,NEUROLOGIC: Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week. The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen. The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding. The patient understands this. I then asked him if the cough was annoying him, he said it was. I offered him a cough syrup, which he agreed to take. The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup. I told to check in three days, if the symptoms were not getting better. The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later. His wife calls me very angry that I did not give him antibiotics. I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.general medicine, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,

PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.orthopedic, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone

CHIEF COMPLAINT:, Status post motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , The patient is a 17-year-old white male who is status post a high-speed motor vehicle accident in which he was ejected from the vehicle. He denies loss of consciousness, although the EMT people report that he did have loss of consciousness. The patient was stable en route. Upon arrival, he complained of headache.,PAST MEDICAL HISTORY:, Medical: None. Surgical: None.,REVIEW OF SYSTEMS: , CARDIAC: No history. PULMONARY: Some morning cough. (Patient is a smoker.),MEDICATIONS:, None.,ALLERGIES:, ALLERGIC TO PENICILLIN, CAUSES SKIN RASH.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 120/80, pulse 82, respirations 20, temperature 36.8°.,HEENT: Contusion over right occipital area. Tympanic membranes benign.,NECK: Nontender.,CHEST: Atraumatic, nontender.,LUNGS: Clear to auscultation and percussion.,ABDOMEN: Flat, soft, and nontender.,BACK: Atraumatic, nontender.,PELVIS: Stable,EXTREMITIES: Contusion over right forearm. No bone deformity or crepitus.,RECTAL: Normal sphincter tone; guaiac negative.,NEUROLOGIC: Glasgow coma scale 15. Pupils equal, round, reactive to light. Patient moves all 4 extremities without focal deficit.,LABORATORY DATA: , Serial hematocrits 42.4, and 40.4. White blood count 6.3. Ethanol: None. Amylase 66. Urinalysis normal. PT 12.6, PTT 29. Chem-7 panel within normal limits.,X-rays of cervical spine and lumbosacral spine within normal limits. X-rays of pelvis and chest within normal limits.,ASSESSMENT:,1. Closed head injury.,2. Rule out intra-abdominal injury.,PLAN:, The patient will be admitted to the trauma surgery service for continued evaluation and treatment for closed head injury as well as possible intra-abdominal injury.nan

PREOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:, Headaches, question of temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion. Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly. The temporal artery was found and exposed in an extension of about 2 cm. The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology. Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion. A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm. This was also proximally and distally ligated with 6-0 Prolene and also side branch. Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well. Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.neurosurgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,

CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode.

INTERPRETATION: , MRI of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal. At C4-C5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise. At C5-C6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise. At C6-C7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina. MRI of the thoracic spine showed normal vertebral body height and alignment. There was evidence of disc generation, especially anteriorly at the T5-T6 level. There was no significant central canal or foraminal compromise. Thoracic cord normal in signal morphology. MRI of the lumbar spine showed normal vertebral body height and alignment. There is disc desiccation at L4-L5 and L5-S1 with no significant central canal or foraminal stenosis at L1-L2, L2-L3, and L3-L4. There was a right paracentral disc protrusion at L4-L5 narrowing of the right lateral recess. The transversing nerve root on the right was impinged at that level. The right foramen was mildly compromised. There was also a central disc protrusion seen at the L5-S1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,IMPRESSION: , Overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing. There was narrowing of the right lateral recess at L4-L5 level and associated impingement of the transversing nerve root at that level by a disc protrusion. This was also seen on a prior study.,neurology, cervical spine, mri, cervical, thoracic, lumbar, transversing nerve root, vertebral body height, vertebral body, disc protrusion, foraminal compromise, central, foraminal, disc, spineNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,POSTOPERATIVE DIAGNOSIS:, Herniated nucleus pulposus, L5-S1 on the left with severe weakness and intractable pain.,PROCEDURE PERFORMED:,1. Injection for myelogram.,2. Microscopic-assisted lumbar laminectomy with discectomy at L5-S1 on the left on 08/28/03.,BLOOD LOSS: , Approximately 25 cc.,ANESTHESIA: , General.,POSITION:, Prone on the Jackson table.,INTRAOPERATIVE FINDINGS:, Extruded nucleus pulposus at the level of L5-S1.,HISTORY: , This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient. ,PROCEDURE DETAIL: ,He was wheeled back to Operating Room #5 at ABCD General Hospital on 08/28/03. After a general anesthetic was administered, a Foley catheter was inserted.,The patient was then turned prone on the Jackson table. All of his bony prominences were well-padded. At this time, a myelogram was then performed. After the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram. The needle was localized to the level of L3-L4 region. Once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle. At this time, approximately 10 cc of Conray injected into the thecal sac. The patient was then placed in the reversed Trendelenburg position in order to assist with distal migration of the contrast. The myelogram did reveal that there was some space occupying lesion, most likely disc at the level of L5-S1 on the left. There was a lack of space filling defect on the left evident on both the AP and the lateral projections using C-arm fluoroscopy. At this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy. A long spinal needle was then inserted into region of surgery on the right. The surgery was going to be on the left. Once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the L5-S1 nerve root region. At this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia. At this time, a Weitlaner was inserted. Bovie cautery was used to obtain hemostasis. We further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina. A Cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side. At this time, a Taylor retractor was then inserted and held there for retraction. Suction as well as Bovie cautery was used to obtain hemostasis. At this time, a small Kerrison Rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression. Once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots. Once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the S1 nerve root, which was compressive. We removed the extruded disc with further freeing up of the S1 nerve root. A nerve root retractor was then placed. Identification of disc space was then performed. A #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade. A small pituitary was then inserted within the disc space and more disc material was freed and removed. The part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc. Once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,At this time, copious irrigation was used to irrigate the wound. We then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur. At this time, a small piece of Gelfoam was then used to cover the exposed nerve root. We did not have any dural leaks during this case. #1-0 Vicryl was then used to approximate the deep lumbar fascia, #2-0 Vicryl was used to approximate the superficial lumbar fascia, and #4-0 running Vicryl for the subcutaneous skin. Sterile dressings were then applied. The patient was then carefully slipped over into the supine position, extubated and transferred to Recovery in stable condition. At this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.surgery, microscopic-assisted lumbar laminectomy, discectomy, nerve root, lumbar laminectomy, herniated nucleus, thecal sac, spinal needle, nucleus pulposus, disc space, root, nerve, weakness, lumbar, laminectomy, nucleus, pulposus, myelogram

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.cardiovascular / pulmonary, heart catheterization, coronary angiography, ventricular angiography, intercoronary stenting, intercoronary, coronary, stenting, stenosis, angiography

CHIEF COMPLAINT: , Altered mental status.,HISTORY OF PRESENT ILLNESS: , This is a 6-year-old white male, who was sent from the Emergency Room with the diagnosis of intracranial bleeding. The patient was found by the 8-year-old sister in the bathroom. He was laying down on one side, and he was crying and moaning. The sibling went and told the parents. The parents rushed to the bathroom, they found him crying, and he was not moving the left side of his body. He was initially alert, but his alertness diminished. They decided to take him to the emergency room in Hospital, where a CT was done on his head, which showed a 4 x 4 x 2.5 cm bleed. The emergency physician called our emergency room, and I decided to involve Neurosurgery, Mr. X, the physician assistant, who is on call for the Neurosurgery Services. Collectively, they have made arrangements with the ICU attendings to have the child transported to our emergency room. For a small stop, I am obtaining an MRI and then admitting to the ICU. History was taken from the parents. He had a history of gastroesophageal reflux disease, otherwise, a healthy child.,MEDICATIONS: , None.,ALLERGIES:, No known drug allergies.,PAST SURGICAL HISTORY: , He had only tympanostomy tubes placed.,FAMILY MEDICAL HISTORY:, Unremarkable.,PHYSICAL EXAMINATION:,GENERAL: He was brought by our transport team. While en route, he was not as alert as he was. He was still oriented. He had to be stimulated via sternal rub to wake up, and saturation went down to the 80s, and he was started on nasal cannula, and code 3 was initiated, and he was rushed to our emergency room. When I saw him, he was lethargic, but arousable. He could recognize where he was, and he could recognize also his parents well.,HEENT: Pupils are 4 mm reactive to direct and indirect light. No signs of trauma is seen on the head. Throat is clear.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm.,ABDOMEN: Soft.,NEUROLOGIC: He has left-sided weakness, but his cranial nerves II through XII are grossly intact.,EMERGENCY DEPARTMENT COURSE: , In the emergency room, at the time when I saw him, Dr. Y and Dr. Z were from the ICU and Anesthesia Services arrived also, and they evaluated the patient with me and pretty much they took care of the patient. They decided to give him a dose of IV mannitol. I ordered his labs, type and cross. CBC is 15.6 white blood cell count, hemoglobin 12.8. PT/PTT were ordered due to the bleed, which was seen intracerebrally. They were 13.1 and 24.5 respectively. Blood gas, I-STAT pH 7.36, pCO2 is 51. This was a venous specimen. The ICU attendings decided to do a rapid sequence intubation. This was done in our emergency room by Dr. Y and Dr. Z. The patient was sent to the MRI, and from where he was going to be admitted to the ICU in critical condition.,DIFFERENTIAL DIAGNOSES: , Arteriovenous malformation, stroke, traumatic injury.,IMPRESSION: , Intracerebral hemorrhage of uncertain etiology to be determined while inpatient.,TIME SPENT:, I spent 30 minutes critical care time with the patient excluding any procedures.,emergency room reports, arteriovenous malformation, stroke, traumatic injury, intracerebral hemorrhage, altered mental status, crying and moaning, mental status, intracranial bleeding, icu attendings, emergency, intracranial, neurosurgery, gastroesophageal, intracerebrally, bleeding, icu,

HISTORY: ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support. He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility. He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site. He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed. Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck. No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY: ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY: ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:, Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL: The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection. The previous incision was vertical in nature and there is no hypertrophic scar formation. No adenopathy noted. No stridor noted.,NEUROLOGIC: Cranial nerve VII intact bilaterally. No signs of tremor.,LUNGS: Diminished breath sounds in all four quadrants. No wheezes noted.,HEART: Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION: ,1. End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2. Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3. History of coronary artery disease.,4. History of myocardial infarction.,5. History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube. His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility. I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed. Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time. The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today. Dressing was applied and we will see him back next week to make sure everything is healing properly.nan

SUBJECTIVE:, The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds. She was diagnosed with type 2 diabetes in 1983. She is not allergic to any medicines.,DIABETES MEDICATIONS:, Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper. Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:, The patient and her daughter completed both days of diabetes education in a group setting. Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician. Fasting blood sugars are 127, 80, and 80. Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63. Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109. Assessment of her knowledge is completed at the end of the counseling session. She demonstrated increased knowledge in all areas and had no further questions. She also completed an evaluation of the class.,The patient's feet were examined during the education session. She had flat feet bilaterally. Skin color was pink, temperature warm. Pedal pulses 2+. Her right second and third toes lay on each other. Also, the same on her left foot. However, there was no skin breakdown. She had large bunions, medial aspect of the ball of both feet. She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care. First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels. Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control. Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control. Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:, Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness. She is to followup with Dr. XYZ for possible reduction in her insulin doses.diets and nutritions, dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,

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

PREOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,POSTOPERATIVE DIAGNOSES:,1. Benign prostatic hypertrophy.,2. Urinary retention.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Transurethral resection of prostate (TURP).,ANESTHESIA: ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS: ,150 cc.,DISPOSITION: ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe. Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder. Cystoscopy performed with the above findings. Cystoscope was removed. A #27 French resectoscope with a #26 cutting loop was inserted into the bladder. Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed. ________ irrigator was used to evacuate the bladder of prostatic chips. Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop. Any obvious bleeding from the prostatic fossa was controlled with electrocautery. Resectoscope was removed. A #24 French three-way Foley catheter inserted into the urethra and into the bladder. Bladder was irrigated and connected to three-way irrigation. The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.surgery, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,

REASON FOR CONSULTATION:, Metastatic ovarian cancer.,HISTORY OF PRESENT ILLNESS: , Mrs. ABCD is a very nice 66-year-old woman who is followed in clinic by Dr. X for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic. She last saw Dr. X in clinic towards the beginning of this month. She has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08. She was last seen in clinic on 12/22/08 by Dr. Y. At that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000. Her ANC was 0.5. She was started on prophylactic Augmentin as well as Neupogen shots. She has also had history of recurrent pleural effusions with the knee for thoracentesis. She had two of these performed in November and the last one was done about a week ago.,Over the last 2 or 3 days, she states she has been getting more short of breath. Her history is somewhat limited today as she is very tired and falls asleep readily. Her history comes from herself but also from the review of the records. Overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions. She was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia. She specifically denied any fevers or chills. However, she was complaining of chest pain. She states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough. When she did cough, it was nonproductive. While in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations. An EKG was performed, which showed sinus rhythm without any evidence of Q waves or other ischemic changes. The chest x-ray described above showed a right lower lobe infiltrate. A V/Q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe. The findings were compatible with an indeterminate study for a pulmonary embolism. Apparently, an ultrasound of the lower extremities was done and was negative for DVT. There was apparently still some concern that this might be pulmonary embolism and she was started on Lovenox. There was also concern for pneumonia and she was started on Zosyn as well as vancomycin and admitted to the hospital.,At this point, we have been consulted to help follow along with this patient who is well known to our clinic.,PAST MEDICAL HISTORY,1. Ovarian cancer - This was initially diagnosed about 10 years ago and treated with surgical resection including TAH and BSO. This has recurred over the last couple of months with metastatic disease.,2. History of breast cancer - She has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago. She has had no recurrent disease.,3. Renal cell carcinoma - She is status post nephrectomy.,4. Hypertension.,5. Anxiety disorder.,6. Chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7. Ongoing tobacco use.,PAST SURGICAL HISTORY,1. Recent and multiple thoracentesis as described above.,2. Bilateral mastectomies.,3. Multiple abdominal surgeries.,4. Cholecystectomy.,5. Remote right ankle fracture.,ALLERGIES:, No known drug allergies.,MEDICATIONS: , At home,,1. Atenolol 50 mg daily,2. Ativan p.r.n.,3. Clonidine 0.1 mg nightly.,4. Compazine p.r.n.,5. Dilaudid p.r.n.,6. Gabapentin 300 mg p.o. t.i.d.,7. K-Dur 20 mEq p.o. daily.,8. Lasix unknown dose daily.,9. Norvasc 5 mg daily.,10. Zofran p.r.n.,SOCIAL HISTORY: , She smokes about 6-7 cigarettes per day and has done so for more than 50 years. She quit smoking about 6 weeks ago. She occasionally has alcohol. She is married and has 3 children. She lives at home with her husband. She used to work as a unit clerk at XYZ Medical Center.,FAMILY HISTORY:, Both her mother and father had a history of lung cancer and both were smokers.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL: She has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount. HEENT: She has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears. CHEST: Per the HPI, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis. CVS: She has had the episodes of chest pains as described above but has not had, PND, orthopnea lower extremity swelling or palpitations. GI: No heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools. GU: No dysuria, burning with urination, kidney stones, and difficulty voiding. MUSCULOSKELETAL: No new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness. NEUROLOGIC: She has been diffusely weak but no lateralizing loss of strength or feeling. She has some chronic neuropathic pain and numbness as described above in the past medical history. She is fatigued and tired today and falls asleep while talking but is easily arousable. Some of this is related to her lack of sleep over the admission thus far.,PHYSICAL EXAMINATION,VITAL SIGNS: Her T-max is 99.3. Her pulse is 54, her respirations is 12, and blood pressure 118/61.,GENERAL: Somewhat fatigued appearing but in no acute distress.,HEENT: NC/AT. Sclerae anicteric. Conjunctiva clear. Oropharynx is clear without any erythema, exudate, or discharge.,NECK: Supple. Nontender. No elevated JVP. No thyromegaly. No thyroid nodules.,CHEST: Clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,CVS: Regular rate and rhythm. No murmurs, gallops or rubs. Normal S1 and S2. No S3 or S4.,ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds. No guarding or rebound. No hepatosplenomegaly. No masses.nan

CHIEF COMPLAINT: ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:, This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well. The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well. The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do. The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house. The patient states that she just simply felt funny and does not give any more specific details than this. The patient denies any pain at any time. She did not have any shortness of breath. No nausea or vomiting. No generalized weakness. The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go. The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved. The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF. The patient was discharged home after evaluation in the emergency room. The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician. The patient denies having any other symptoms today. The patient denies any fever or chills. Has not had any recent weight change. HEENT: The patient denies any headache. No neck pain. No rhinorrhea. No sinus congestion. No sore throat. No any vision or hearing change. No eye or ear pain. CARDIOVASCULAR: The patient denies any chest pain. RESPIRATIONS: No shortness of breath. No cough. No wheeze. The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. No change in the bowel movements. There has not been any diarrhea or constipation. No melena or hematochezia. GENITOURINARY: No dysuria, hematuria, urgency, or frequency. MUSCULOSKELETAL: No back pain. No muscle or joint aches. No pain or abnormalities to any portion of the body. SKIN: No rashes or lesions. NEUROLOGIC: The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days. The patient denies any dizziness at this time. No syncope or no near-syncope. The patient denies any focal weakness or numbness. No speech change. No difficulty with ambulation. The patient has not had any vision or hearing change. PSYCHIATRIC: The patient denies any depression. ENDOCRINE: No heat or cold intolerance.,PAST MEDICAL HISTORY:, COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:, Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear sclerae and cornea bilaterally. Nose is normal without rhinorrhea or audible congestion. Mouth and oropharynx are normal without any sign of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. No cervical lymphadenopathy. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +2. The patient does have +1 bilateral lower extremity edema. RESPIRATIONS: The patient has coarse breath sounds bilaterally, but no dyspnea. Good air movement. No wheeze. No crackles. The patient speaks in full sentences without any difficulty. The patient does not exhibit any retractions, accessory muscle use or abdominal breathing. GASTROINTESTINAL: Abdomen is soft, nontender, and nondistended. No rebound or guarding. No hepatosplenomegaly. Normal bowel sounds. No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy. MUSCULOSKELETAL: No abnormalities noted to the back, arms or legs. SKIN: No rashes or lesions. NEUROLOGICAL: Cranial nerves II through XII are intact. Motor is 5/5 and equal to bilateral arms and legs. Sensory is intact to light touch. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her. The patient has normal mood and affect. HEMATOLOGIC AND LYMPHATIC: There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture. There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08. CBC has no specific abnormalities of issue. Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20. The rest of the values are normal and unremarkable. LFTs are all within normal limits. Cardiac enzymes are all within normal limits. Digoxin level is therapeutic at 1.6. Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago. CAT scan of the head did not identify any acute abnormalities. I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day. I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past. The neighbor is XYZ and he says that he checks on her three times a day every day. ABC is the patient's son and although he lives out of town he calls and checks on her every day as well. He states that he spoke to her yesterday. She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician. She sounded her usual self to him. Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him. He states that he will be able to check on her tomorrow as well. Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements. The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well. The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1. EARLY DEMENTIA.,2.nan

PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:, The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure. Oxygenation was given. The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE: ,The patient remained awake throughout the procedure in order to interact and give feedback. The x-ray technician was supervised and instructed to operate the fluoroscopy machine. The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine. With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***. Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves. Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts. Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue. After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds. All injected medications were preservative free. Sterile technique was used throughout the procedure.,COMPLICATIONS:, None. No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.surgery, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,

DISCHARGE DIAGNOSES:,1. Central nervous system lymphoma.,2. Gram-negative bacteremia.,3. Pancytopenia.,4. Hypertension.,5. Perianal rash.,6. Diabetes mellitus.,7. Hypoxia.,8. Seizure prophylaxis.,9. Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1. Cycle five high-dose methotrexate.,2. Rituxan weekly.,3. Chest x-ray.,4. Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion. Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable. She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania. During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen. Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1. CNS lymphoma. Upon admission, she was started on her Rituxan, which she tolerated well. She was then hydrated with bicarbonate solution to a urine pH of 8. She received methotrexate 5 g/m2. 24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08. This was likely secondary to the need to initiate treatment with antibiotics secondary to infection. Her leucovorin was increased to 100 mg/m2. 72-hour methotrexate level was 0.58. 96-hour methotrexate was 0.16, and 19-hour was 0.08. She continued additional four doses of oral leucovorin. Her creatinine improved. On day prior to discharge, she received her weekly dose of Rituxan. She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2. Gram-negative bacteremia. On the morning of June 27, 2008, Ms. ABC did spike a fever. She was started on empiric antibiotics with cefepime and vancomycin. Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours. After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization. Both cultures eventually grew out Proteus mirabilis, which was pansensitive. She had three additional blood cultures, which were all negative. On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile. We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime. She will continue this with the assistance of home health services. She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient. She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3. Pancytopenia. On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000. Her labs will be followed closely as an outpatient. During the admission, we did obtain a HIT antibody, which was negative. Heparin was held until this level was returned. She was placed on Arixtra for prophylaxis against thrombus. It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4. Hypertension. Blood pressure remained stable throughout the admission. She will continue lisinopril daily.,5. Perianal rash. Upon admission, she was found to have worsening of a candidal rash in the perianal region. A wound consult was obtained. They recommended Aloe Vesta foam and Silver gel to the area topically. She was also continued on Diflucan 200 mg daily. She will complete a 10-day course.,6. Diabetes mellitus. At the time of admission, she was found to have hyperglycemia. She was started on sliding scale insulin and eventually started on long-acting Lantus insulin. She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7. Hypoxia. She did have evidence of decreased saturations. There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8. Seizure prophylaxis. She will continue Keppra twice daily.,9. Acute kidney injury. She did have a bump in the creatinine when methotrexate level was elevated. This resolved by the time of discharge. Creatinine on day of discharge is 0.9. This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:, Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008. Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call.nan

REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general "OK," but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above.nan

EXAM: , Screening full-field digital mammogram.,HISTORY:, Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed. The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left. There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast. The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue. There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes. A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified. The skin is stable. No enlarged axillary lymph node is seen.,IMPRESSION:,1. No significant interval changes are seen. No mammographic evidence of malignancy is identified.,2. Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.obstetrics / gynecology, digital mammography, full-field digital mammogram, ffdm, second look version, field digital mammogram, digital mammogram, breast cancer, mammographic, icad, microcalcifications, mammogram, screening, digital, mammography, breast

PREOPERATIVE DIAGNOSIS:, Aortic stenosis.,POSTOPERATIVE DIAGNOSIS: ,Aortic stenosis.,PROCEDURES PERFORMED,1. Insertion of a **-mm Toronto stentless porcine valve.,2. Cardiopulmonary bypass.,3. Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 300 cc.,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid.,URINE OUTPUT: , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:, After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next the neck, chest and legs were prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make a midline median sternotomy incision. Dissection was carried down to the left of the sternum using Bovie electrocautery. The sternum was opened with a sternal saw. The chest retractor was positioned. Next, full-dose heparin was given. The pericardium was opened. Pericardial stay sutures were positioned. After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass. A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta. Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine. Next a 3-0 Prolene pursestring was placed in the right atrial appendage. Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine. A 4-0 U-stitch was placed in the right atrium. A retrograde cardioplegia catheter was positioned at this site. Next, scissors were used to dissect out the right upper pulmonary vein. A 4-0 Prolene pursestring was placed in the right upper pulmonary vein. Next, a right-angle sump was placed at this position. We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit. Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery. The aorta was completely encircled. Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta. We then prepared to cross-clamp the aorta. We went down on our flows and cross-clamped the aorta. We backed up our flows. We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart. The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit. Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures. In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view. Next, scissors were used to excise the diseased aortic valve leaflets. Care was taken to remove all the calcium from the aortic annulus. We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve. We prepared the valve. Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus. We started with our individual commissural stitches. They were connected to our valve sewing ring. Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position. After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve. The valve was lowered into place and all of the sutures were tied. Next, we gave another round of cold blood antegrade and retrograde cardioplegia. Next, we sewed our distal suture line. We began with the left coronary cusp of the valve. We ran a 5-0 RB needle up both sides of the valve. Care was taken to avoid the left coronary ostia. This procedure was repeated on the right cusp of the stentless porcine valve. Again, care was taken to avoid any injury to the coronary ostia. Lastly, we sewed our non-coronary cusp. This was done without difficulty. At this point we inspected our aortic valve. There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open. We gave another round of cold blood antegrade and retrograde cardioplegia. The antegrade portion was given in a direct ostial fashion once again. We now turned our attention to closing the aorta. A 4-0 Prolene double row of suture was used to close the aorta in a running fashion. Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia. At this point, we removed our aortic cross-clamp. The heart gradually regained its electromechanical activity. We placed 2 atrial and 2 ventricular pacing wires. We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle. We removed our retrograde cardioplegia catheter. We oversewed that site with a 5-0 Prolene. By now, the heart was de-aired and resumed normal electromechanical activity. We began to wean the patient from cardiopulmonary bypass. We then removed our venous cannula and suture ligated that site with a #2 silk. We then gave full-dose protamine. After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula. We buttressed that site with a 4-0 Prolene on an SH needle. We placed a mediastinal chest tube and brought it out through the skin. We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions. They were brought out through the skin. The sternum was closed with #7 wires in an interrupted figure-of-eight fashion. The fascia was closed with #1 Vicryl. We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,

PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY: ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling. The patient was started on alpha-blockers with some help, but had nocturia q.1h. The patient was given anticholinergics with minimal to no help. The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate. At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream. Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed. The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder. The patient was told that he may need anticholinergics. There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL: ,The patient was brought to the OR and anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was given preoperative antibiotics. The patient was prepped and draped in the usual sterile fashion. A #23-French scope was inserted inside the urethra into the bladder under direct vision. Bilateral pyelograms were normal. The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder. There was enlargement of the lateral lobes of the prostate. The old TUR scar was visualized right at the bladder neck. Using diode side-firing fiber, the lateral lobes were taken down. The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure. Pictures were taken and were shown to the family. At the end of the procedure, there was good hemostasis. A total of about 15 to 20 minutes of lasering time was used. A #22 3-way catheter was placed. At the end of the procedure, the patient was brought to recovery in stable condition. Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.surgery, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain. She had been previously diagnosed with hyperthyroidism. Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm. She had been experiencing palpitations and tachycardia. She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3. Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively. Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency. She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards. She complained of sweating, but has experienced no diarrhea and no change in appetite. She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:, Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:, She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use.,MEDICATIONS:, Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT: She has exophthalmos and could not close her lids completely.,Cardiovascular: tachycardia.,Neurologic: She had mild hyperreflexiveness.,LAB:, All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry. On the 2nd day of treatment, the patient still complained of chest pain. EKG again showed tachycardia. Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours. The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake. Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131. She was to return home after the iodine treatment. She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism. Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism. Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism. She should return to Endocrine Clinic in six weeks to have thyroid function tests performed. Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy. Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health. Patient was given methylcellulose ophthalmic, one drop in each eye daily. She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression. Patient will be continued on citalopram 10 mg.endocrinology, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

PROCEDURE PERFORMED:,1. Left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2. PCI of the LAD and left main coronary artery with Impella assist device.,INDICATIONS FOR PROCEDURE: , Unstable angina and congestive heart failure with impaired LV function.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile manner. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 7-French sheath was introduced into the right common femoral artery and a 6-French sheath was introduced into the right common femoral vein. Through the arterial sheath, angiography of the right common femoral artery was obtained. Thereafter, 6-French pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained. Thereafter, a 4-French sheath was introduced into the left common femoral artery using modified Seldinger technique. Thereafter, the pigtail catheter was advanced over an 0.035-inch J-wire into the left ventricle and LV-gram was performed in RAO view and after pullback, an aortogram was performed in the LAO view. Therefore, a 6-French JL4 and JR4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,ANGIOGRAPHIC FINDINGS: ,1. LV-gram: LVEDP was 15 mmHg. LV ejection fraction 10% to 15% with global hypokinesis. Only anterior wall is contracting. There was no mitral regurgitation. There was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2. The right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated. The left main coronary artery calcified vessel with disease.,2. The left anterior descending artery had an 80% to 90% mid-stenosis. First diagonal branch had a more than 90% stenosis.,3. The circumflex coronary artery had a patent stent.,INTERVENTION: , After reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery. The 4-French sheath in the left common femoral artery was upsized to a 12-French Impella sheath through which an Amplatz wire and a 6-French multipurpose catheter were advanced into the left ventricle. The Amplatz wire was exchanged for an Impella 0.018-inch stiff wire. The multipurpose catheter was removed, and the Impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min. Thereafter, a 7-French JL4 guiding catheter was used to engage the left coronary artery and an Asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch Asahi soft wire was advanced into the diagonal branch. The diagonal branch was predilated with a 2.5 x 30-mm Sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 Endeavor stent was successfully deployed in the mid-LAD and a 3.0 x 15-mm Endeavor stent was deployed in the proximal LAD. The stent delivery balloon was used to post-dilate the overlapping segment. The LAD, the diagonal was rewires with an 0.014-inch Asahi soft wire and a 3.0 x 20-mm Maverick balloon was advanced into the LAD for post-dilatation and a 2.0 x 30-mm Sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres. At this point, it was noted that the left main had a retrograde dissection. A 3.5 x 18-mm Endeavor stent was successfully deployed in the left main coronary artery. The Asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery. Kissing inflations of the LAD and the circumflex coronary artery were performed using 3.0 x 20 Maverick balloons x2 balloons, inflated at high atmospheres of 14.,RESULTS: , Lesion reduction in the LAD FROM 90% to 0% and TIMI 3 flow obtained. Lesion reduction in the diagonal from 90% to less than 60% and TIMI 3 flow obtained. Lesion reduction in the left maintained coronary artery from 50% to 0% and TIMI 3 flow obtained.,The patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability. The Impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the Impella was removed from the body and the 2 Perclose sutures were tightened. From the right common femoral artery, a 6-French IMA catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes. The right common femoral artery and vein sheaths were both sutured in place for further observation. Of note, the patient received Angiomax during the procedure and an ACT above 300 was maintained.,IMPRESSION:,1. Left ventricular dysfunction with ejection fraction of 10% to 15%.,2. High complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with Impella circulatory support.,COMPLICATIONS: , None.,The patient tolerated the procedure well with no complications. The estimated blood loss was 200 ml. Estimated dye used was 200 ml of Visipaque. The patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,PLAN: ,1. Aspirin, Plavix, statins, beta blockers, ACE inhibitors as tolerated.,2. Hydration.,3. The patient will be observed over night for any hemodynamic instability or ischemia. If she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.cardiovascular / pulmonary, impella circulatory assist device, impella assist device, unstable angina, congestive heart failure, heart catheterization, ventriculogram, aortogram, angiogram, ventricular dysfunction, pigtail catheter was advanced, femoral artery and vein, artery and vein, asahi soft wire, circumflex coronary artery, common femoral artery, modified seldinger technique, multiple stent placements, timi flow, multiple stent, impella circulatory, french sheath, femoral artery, endeavor stent, descending artery, coronary artery, common femoral, asahi soft, anterior descending, femoral, coronary, artery, impella, catheterization,

SUBJECTIVE:, This 9-month-old Hispanic male comes in today for a 9-month well-child check. They are visiting from Texas until the end of April 2004. Mom says he has been doing well since last seen. He is up-to-date on his immunizations per her report. She notes that he has developed some bumps on his chest that have been there for about a week. Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics. Mom says he has been doing fine since then. She has no concerns about him.,PAST MEDICAL HISTORY:, Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:, None.,SOCIAL HISTORY:, Lives with parents. There is no smoking in the household.,REVIEW OF SYSTEMS:, Developmentally is appropriate. No fevers. No other rashes. No cough or congestion. No vomiting or diarrhea. Eating normally.,OBJECTIVE:, His weight is 16 pounds 9 ounces. Height is 26-1/4 inches. Head circumference is 44.75 cm. Pulse is 124. Respirations are 26. Temperature is 98.1 degrees. Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT: Normocephalic, atraumatic. Anterior fontanel is soft and flat. Tympanic membranes are clear bilaterally. Conjunctivae are clear. Pupils equal, round and reactive to light. Nares without turbinate edema. Oropharynx is nonerythematous.,NECK: Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm, without murmur.,ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No masses or organomegaly to palpation.,GU: Normal male external genitalia. Uncircumcised penis. Bilaterally descended testes. Femoral pulses 2/4.,EXTREMITIES: Moves all four extremities equally. Minimal tibial torsion.,SKIN: Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1. Well-child check. Is doing well. Will recommend a followup well-child check at 1 year of age and immunizations at that time. Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom. She is given a parenting guide handout.,2. Molluscum contagiosum. Described the viral etiology of these. Told her they are self limited, and we will continue to monitor at this time.,3. Left otitis media, resolved. Continue to monitor. We will plan on following up in three months if they are still in the area, or p.r.n.pediatrics - neonatal, well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child,

CHIEF COMPLAINT:, Irritable baby with fever for approximately 24 hours.,HISTORY OF PRESENT ILLNESS:, This 6-week-old infant was doing well until about 48 hours prior to admission, developed irritability, fussiness, a little bit of vomiting, and then fever up to 103-degrees. The child was brought into the emergency room and a complete septic workup was done, and the child is being treated in a rule out sepsis protocol.,PAST MEDICAL HISTORY:, This child was born by term pregnancy, spontaneous vaginal delivery, to a mother who was a teenager. He is bottle fed and he has had his hepatitis B vaccine. He lives in a home where there are smokers. This is his first illness.,PAST SURGICAL HISTORY:, He has had no previous surgeries.,MEDICATION (S):, He takes no medications on a regular basis.,REVIEW OF SYSTEMS:, Positive for those things mentioned already in the past medical history and history of present illness.,FAMILY HISTORY:, The family history is noncontributory.,SOCIAL HISTORY:, This child lives with his mother and father, both are teenagers, unmarried, who are not well educated. Grandmother is a heavy smoker.,PHYSICAL EXAMINATION:,VITAL SIGNS: The vital signs are stable, the patient is febrile at 101-degrees.,HEAD, EYES, EARS, NOSE, AND THROAT/GENERAL: The anterior fontanelle is not bulging. The rest of the examination is within normal limits. The neck is supple, no nuchal rigidity noted, though this child is irritable and fussy, and whines and cries where ever you make touch him. He has an irritable disposition no matter what you do to him, and whines even while at rest.,HEART: The heart rate is rapid, but there was no murmur noted.,LUNGS: The lungs are clear.,ABDOMEN: The abdomen is without mass, distention, or visceromegaly.,GENITOURINARY/RECTAL: Examination within normal limits.,EXTREMITIES: The extremities are normal. No Kernig's or Brudzinski sign.,NEUROLOGIC: Cranial nerves II through XII are intact, no focal deficits. As I mentioned before, the child is extremely irritable, fussy, and has a great deal of general inconsolability.,SKIN: The child, in addition, has a skin pattern of cutis marmorata, which I think is a bit more exaggerated since the child is febrile and has some peripheral vasodilatation.,CLINICAL IMPRESSION (S):, Likely viral syndrome, viral meningitis, flu syndrome.,PLAN:, Continue the septic workup protocol, supportive care with IV fluids, and Tylenol as needed for fever, and continue the antibiotics until spinal fluid cultures and blood cultures are negative for 48 hours. In addition, I believe that the rapid heart rate is a sinus tachycardia, and is related to the child's illness, irritability, and his fever. In addition, there were no intracranial bruits noted.nan

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body.,PROCEDURES PERFORMED:,1. Direct laryngoscopy with intubation by surgeon.,2. Rigid tracheoscopy.,3. Rigid esophagoscopy with removal of foreign body.,INDICATIONS: , The patient is an 8-month-old Hispanic male, who presented to the Emergency Department with approximately 12-hour history of choking event and presumed for esophageal foreign body. When seen in the Emergency Department, he was having no difficulty managing his secretions or any signs of any airway compromise. Imaging in the Emergency Department did demonstrate an esophageal foreign body at or above the level of the cricopharyngeus. Due to this, the patient was consented and taken urgently to the operating room for removal of this foreign body.,OPERATIVE DETAILS:, The patient was correctly identified in the preop holding area and brought to operating room #37. After informed consent was reviewed, general anesthesia was induced, initially with propofol, the existing IV. Following this after protective eye tape was placed, #9 Parson's laryngoscope was introduced transorally and used to perform a direct laryngoscopy. Normal anatomy was visualized. Following this, a 4-mm, 20-rigid endoscope was introduced through the Parson's laryngoscope and used to perform a direct tracheoscopy. The patient's supraglottis, glottis, and subglottis down to the level of the mid trachea were found to be benign with no abnormal-appearing anatomy. Following this, the rigid endoscope was removed and the patient was intubated with a 4-0 endotracheal tube cuffed without difficulty. After confirming bilateral breath sounds and positive end tidal CO2, this was secured to the patient by the anesthesia staff. Following this, the Parson's laryngoscope was removed and a size 4 rigid esophagoscope was inserted transorally and passed down to the level of the patient's cricopharyngeus were the foreign body was visualized. At this point, the coin grasper device was connected to the camera system and inserted through the existing esophagoscope. This was used to grasp the coin and the coin was removed under direct visualization and handed off as a separate specimen. Following this, the 34 mm 0-degree scope was inserted through the esophagoscope once the esophagoscope was passed down to the patient's GE junction. The entire esophageal mucosa was examined as the esophagoscope was backed out and there was only a minimal amount of superficial ulceration in the posterior wall of the esophagus near the level of the cricopharyngeus muscle. There were no other lesions or signs of further esophageal damage. Following this, all instrumentation was removed, and care of the patient was turned back to the anesthesia staff for stable wakeup.,FINDINGS:,1. Normal supraglottic, glottic, and subglottic anatomy.,2. Esophageal foreign body at the level of the cricopharyngeus.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, None.,DISPOSITION: , Stable to the PACU and then home.surgery, rigid tracheoscopy, rigid esophagoscopy, subglottic, supraglottic, glottic, removal of foreign body, level of the cricopharyngeus, esophageal foreign body, foreign body, rigid endoscope, direct laryngoscopy, emergency department, parson's laryngoscope, foreign, esophagoscopy, tracheoscopy, transorally, laryngoscopy, anesthesia, parson's, laryngoscope, endoscope, cricopharyngeus, esophagoscope, esophageal

ADMISSION DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1. Neck pain with right upper extremity radiculopathy.,2. Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1. Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2. Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3. Spinal instrumentation C4 through C7.,4. Implant.,5. Allograft.,COMPLICATIONS:, None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand. The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now. The patient has been treated with medications, which has been unrelenting. The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7. The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine. The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger. The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol. The patient will have continued pain medication coverage with Darvocet and Flexeril. The patient will follow up with me as scheduled. Instructions have been given.discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,

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

Quick note on tachypnea.office notes, chest, cpr, breath sounds, tachypnea, epinephrine, rhythmNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot. It often first appears between the toes. It can be a one-time occurrence or it can be chronic. The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible. It is easily transmitted in showers and pool walkways. Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,* Itchy feet.,* White or red and soft scaling on feet, usually in between toes.,* Small blisters may be present.,* Bad foot odor.,* Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,* Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope.. A bacterial infection may also be suspected in which case a skin culture will confirm this.,* Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,* Oral antibiotics may be prescribed for a possible bacterial infection.,* Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton. Go barefoot when you have a chance or wear sandals. Dry thoroughly in between toes after swimming or bathing.,* A special powder to absorb moisture on feet is also available in drugstores. Ask the pharmacist about this.,* Spray your shower at home with a 10% bleach solution after bathing. This may help decrease the chance that other family members will be infected.,* Wear sandals or thongs in public showers and around pools.,* Keep in mind that it may take up to a month or more to get rid of your athlete's foot. Be diligent in using the antifungal medication. Unfortunately, recurrence of athlete's foot is common. Luckily, the condition does not cause serious problems for the majority of people who have it.,* Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1. Raise toes toward you while bending your ankle as high as you can.,2. Hold this position for 15 seconds.,3. Alternate doing this with the opposite foot 10 times.,4. Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1. Clean the area daily with soap and water.,2. Every day apply a thin coat of polysporin ointment.,3. Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4. Notify the office if you have any increasing wound pain or any evidence of infection.podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's,

HISTORY:, The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improvement. She has loose bowel movements. She complains of no bladder control. She has pain in her hips. The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1. Type II diabetes mellitus.,2. Generalized fatigue and weakness.,3. Hypertension.,4. Peripheral neuropathy with atypical symptoms.,5. Hypothyroidism.,6. Depression.,7. Long-term use of high-risk medications.,8. Postmenopausal age-related symptoms.,9. Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.,PAST SURGICAL HISTORY:, As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy.,SOCIAL HISTORY: ,She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL: Certainly at the present time on general exam no fever, sweats or chills and no significant weight change. She is 189 pounds currently and she was 188 pounds in January.,HEENT: HEENT, there is no marked decrease in visual or auditory function. ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY: Chest, there is no history of palpitations, PND or orthopnea. The chest pains are nonspecific, tenderness to palpation has been reported. There is no wheezing or cough reported.,CARDIOVASCULAR: No PND or orthopnea. Thromboembolic disease history.,GASTROINTESTINAL: Intermittent symptoms of stomach pain, they are nonspecific. No nausea or vomiting noted. Diarrhea is episodic and more related to nerves.,GENITOURINARY: She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL: Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL: No marked paralysis, paresis or paresthesias.,SKIN: No rashes, itching or changes in the nails.,BREASTS: No report of any lumps or masses.,HEMATOLOGY AND IMMUNE: No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT: 189 pounds. BP: 140/80. PULSE: 76. RESPIRATIONS: 20. GENERAL APPEARANCE: Well developed, well nourished. No acute distress.,HEENT: Head is normocephalic. Ears, nose, and throat, normal conjunctivae. Pupils are reactive. Ear canals are patent. TMs are normal. Nose, nares patent. Septum midline. Oral mucosa is normal in appearance. No tonsillar lesions, exudate or asymmetry. Neck, adequate range of motion. No thyromegaly or adenopathy.,CHEST: Symmetric with clear lungs clear to auscultation and percussion.,HEART: Rate and rhythm is regular. S1 and S2 audible. No appreciable murmur or gallop.,ABDOMEN: Soft. No masses, guarding, rigidity, tenderness or flank pain.,GU: No examined.,EXTREMITIES: No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS: Intact. No lesions or rashes.,NEUROLOGIC: Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,nan

CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:, A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly., ,PAST MEDICAL HISTORY:, Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt: 185 B/P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.,General: A 70-year-old female who does not appear to be in acute distress. ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull.nan

HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES: ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. The left median sensory distal latency is prolonged with an attenuated evoked response amplitude. The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. The right median motor distal latency and evoked response amplitude is normal. Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal.,NEEDLE EMG:, Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. There is increased insertional activity in the right first dorsal interosseous muscle. Both interosseous muscles showed signs of reinnervation. Left extensor digitorum communis muscle showed evidence of reduced recruitment. Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal. It reveals the following: A left median neuropathy at the wrist consistent with carpal tunnel syndrome. Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies. This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ. She will follow up with Dr. XYZ with respect to treatment of the above conditions.physical medicine - rehab, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction,

CHIEF COMPLAINT:, Achilles ruptured tendon.,HISTORY:, Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola. He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg. He was seen locally and diagnosed with an Achilles tendon rupture. He has been on crutches and has been nonweightbearing since that time. He had no pain prior to his injury. He has had some swelling that is mild. He has just been on aspirin a day due to his traveling time. Pain currently is minimal.,PAST MEDICAL HISTORY:, Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:, Malarone, which is an anti-malarial.,ALLERGIES:, NKDA,SOCIAL HISTORY:, He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.,PHYSICAL EXAM:, Pleasant gentleman in no acute distress. He has some mild swelling on the right ankle and hindfoot. He has motion that is increased into dorsiflexion. He has good plantarflexion. Good subtalar, Chopart and forefoot motion. His motor function is intact although weak into plantarflexion. Sensation is intact. Pulses are strong. In the prone position, he has diminished tension on the affected side. There is some bruising around the posterior heel. He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him. Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:, Of his right ankle today show a preserved joint space. I don't see any evidence of fracture noted. Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:, Right Achilles tendon rupture.,PLAN:, I have gone over with Mr. XYZ the options available. We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment. Based on his age and his activity level, I think his best option is for operative fixation. We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery. We have discussed doing this as an outpatient procedure. He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼" lift. He understands a 6-9 month return to sports overall. He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola. Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1" lift also. He can weight bear until surgery and we will have it set up this week. His questions were all answered today.orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles,

CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" 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&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.neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram,

DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. The left vas was grasped in between the fingers. The skin and vas were anesthetized with local anesthesia. The vas was grasped with an Allis clamp. Skin was incised and the vas deferens was regrasped with another Allis clamp. The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side. Dry sterile dressings were applied and the patient put on a scrotal supporter. The procedure was then terminated.urology, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:, Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED: ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL: ,Patient was prepped and draped in sterile fashion. Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened. The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed. Diskectomy and fusion, which will be separately dictated by Dr. X, were performed. Once this was completed, all hemostasis was confirmed. The preperitoneal space was reduced. X-ray confirmed adequate positioning and fusion. Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's. Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.surgery, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,

HISTORY OF PRESENT ILLNESS: , The patient is a 62-year old male with a Gleason score 8 adenocarcinoma of the prostate involving the left and right lobes. He has a PSA of 3.1, with a prostate gland size of 41 grams. This was initially found on rectal examination with a nodule on the right side of the prostate, showing enlargement relative to the left. He has undergone evaluation with a bone scan that showed a right parietal lesion uptake and was seen by Dr. XXX and ultimately underwent an open biopsy that was not malignant. Prior to this, he has also had a ProstaScint scan that was negative for any metastatic disease. Again, he is being admitted to undergo a radical prostatectomy, the risks, benefits, and alternatives of which have been discussed, including that of bleeding, and a blood transfusion.,PAST MEDICAL HISTORY: , Coronary stenting. History of high blood pressure, as well. He has erectile dysfunction and has been treated with Viagra.,MEDICATIONS: , Lisinopril, Aspirin, Zocor, and Prilosec.,ALLERGIES:, Penicillin.,SOCIAL HISTORY:, He is not a smoker. He does drink six beers a day.,REVIEW OF SYSTEMS: , Remarkable for his high blood pressure and drug allergies, but otherwise unremarkable, except for some obstructive urinary symptoms, with an AUA score of 19.,PHYSICAL EXAMINATION:,HEENT: Examination unremarkable.,Breasts: Examination deferred.,Chest: Clear to auscultation.,Cardiac: Regular rate and rhythm.,Abdomen: Soft and nontender. He has no hernias.,Genitourinary: There is a normal-appearing phallus, prominence of the right side of prostate.,Extremities: Examination unremarkable.,Neurologic: Examination nonfocal.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Erectile dysfunction.,PLAN: ,The patient will undergo a bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. The risks, benefits, and alternatives of this have been discussed. He understands and asks that I proceed ahead. We also discussed bleeding and blood transfusions, and the risks, benefits and alternatives thereof.urology, gleason score, gleason, prostate gland, prostascint, retropubic prostatectomy, adenocarcinoma of the prostate, erectile dysfunction, adenocarcinoma, radical, prostatectomy, erectile, dysfunction, prostate,

GENERAL:, Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES:, Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:, No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.,MUSCULOSKELETAL:, Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.general medicine, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She states that she continues with some joint pain and feeling tired all the time. Mother states that also her seizure has continued without any control so far. She is having some studies in the next few days. She is mostly stiff on her legs, neck, and also on her hands. The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT: She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations. Pupils are reactive to accommodation. Funduscopic examination is within normal limits.,NECK: No neck masses.,CHEST: Clear to auscultation.,HEART: Regular rhythm with no murmur.,ABDOMEN: Soft, nontender with no visceromegaly.,SKIN: No rashes today.,MUSCULOSKELETAL: Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D. She also has chronic proteinuria and seizure disorder. My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking. We are going to refer her to physical therapy and see her back in 2 months for followup. The plan was discussed with A and her parents and they have no further questions.consult - history and phy., arthralgias, deficiency, vitamin d, collagen vascular diseases, seizure disorder, vascular diseases, joint pains, oligoarticular arthritis, arthritis, oligoarticular,

EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:, None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery. There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:, Right CCA PSV 0.72 m/s. Right ICA PSV is 0.595 m/s. Right ICA EDV 0.188 m/s. Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s. Left ICA EDV 0.192 m/s. Left vertebral 0.551 m/s. Left IC/CC is 1.047.,IMPRESSION:,1. No evidence for clinically significant stenosis.,2. Minimal, predominantly soft plaquing.,cardiovascular / pulmonary, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,

PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers release A1 pulley.,TOURNIQUET TIME: ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1. A compressed median nerve at the carpal tunnel, which was flattened.,2. A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers. After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY: ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left. He had positive EMG findings as well as clinical findings. The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE: ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03. He was placed supine on the operating room table. Next, a non-sterile tourniquet was placed on the right forearm, but not inflated. At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia. In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers. At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure. First, we went for release of the carpal tunnel. Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region. First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally. The palmaris brevis muscle was then identified and sharply transected. At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia. Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized. The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly. At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel. At this time, copious irrigation was used to irrigate the wound. The wound was suctioned dry. At this time, we proceeded to the release of the A1 pulleys. Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers. First, we went for the index finger. Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley. A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally. Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity. There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons. Once a thorough release was performed, copious irrigation was used to irrigate that wound. In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger. A Littler scissor was used to bluntly dissect in the longitudinal fashion. With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally. We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity. Again, there was evidence of some synovitis as well as fraying of both tendons. The girth of both tendons and both wounds were within normal limits. At this time, copious irrigation was used to irrigate the wound. The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively. In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact. At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger. The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery. At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll. The patient was then carefully taken off of the operating room table to Recovery in stable condition.orthopedic, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,

PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.orthopedic, toenail, nail matrix, ingrown toenail, painful, ingrown,

3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.radiology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

EXAM:, Skull, complete, five images,HISTORY:, Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated. There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is no evidence of any craniosynostosis. There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.pediatrics - neonatal, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull,

PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:, Cysto stent removal.,ANESTHESIA:, Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose. The patient was on vancomycin for the last 5 days.,BRIEF HISTORY: ,The patient is a 53-year-old female who presented with Enterococcus urosepsis. CT scan showed a lower pole stone with a stent in place. The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology. The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone. There was some pus that came out. The patient was cultured; actually it was negative at that time. The patient subsequently was found to have lower extremity DVT and then was started on Coumadin. The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE. The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact. The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers. The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated. Due to drug interaction, the patient was admitted for IV antibiotic treatment. The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed. Since the stone is not obstructing, there is no reason to replace the stent at this time. We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated. So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient. Risks, benefits, and options were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed. The patient understood all the risks and benefits of removing the stent and wanted to proceed. The patient was brought to the OR. The patient was placed in dorsal lithotomy position. The patient was given some IV pain meds. The patient had received vancomycin and Levaquin preop. Cystoscopy was performed using graspers. The stent was removed without difficulty. Plan was for repeat cultures and continuation of the IV antibiotics.nephrology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,

PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:, Bilateral vasectomy.,ANESTHESIA:, Local.,INDICATIONS FOR PROCEDURE: ,A gentleman who is here today requesting voluntary sterility. Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table. Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. A small incision was made in the right hemiscrotum. The vas deferens was grasped with a vas clamp. Next, the vas deferens was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum. The vas deferens was isolated. It was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin. A jockstrap and sterile dressing were applied at the end of the case. Sponge, needle, and instruments counts were correct.surgery, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp: Patient denies asthma, lung infections and lung lesions.,GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology: Patient denies allergic reactions, rashes and skin lesions.,MEDS:, Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:, No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:, No significant family history.,REVIEW OF SYSTEMS:, Non-contributory.,Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm. Patient is afebrile.,Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, or normal size and conto.,Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.,Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood pressure is equal bilaterally.,Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness. No hernias are noted.,Extremities: There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled. Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC. ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.nan

PREOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1. Left pilon fracture.,2. Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1. External fixation of left pilon fracture.,2. Closed reduction of left great toe, T1 fracture.,ANESTHESIA: ,General.,BLOOD LOSS: ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:, None.,INDICATION FOR OPERATION: ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009. The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time. The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness. She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention. Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation. The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome. Risks and benefits of procedure were discussed in detail with the patient and her husband. All questions were answered, and consent was obtained. The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1. There was a comminuted distal tibia fracture with a fibular shaft fracture. Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2. The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement. As the reduction was stable with buddy taping, no pinning was performed.,3. Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL: ,The patient was identified in the preoperative holding area. The left leg was identified and marked at the surgical site of the patient. She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team. She received Ancef for antibiotic prophylaxis. A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics. When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion. At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site. A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able. When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture. Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive. X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture. At this point, the pins were cut short and capped to protect the sharp ends. The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition. Please note there was no break in sterile technique throughout the case.,PLAN: ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication. She will maintain her buddy taping in regards to her great toe fracture.orthopedic, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

PREOPERATIVE DIAGNOSIS: ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1. Right ureteropelvic junction obstruction.,2. Severe intraabdominal adhesions.,3. Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1. Laparoscopic lysis of adhesions.,2. Attempted laparoscopic pyeloplasty.,3. Open laparoscopic pyeloplasty.,ANESTHESIA:, General.,INDICATION FOR PROCEDURE: ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent. The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic. The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction. Hassan technique was performed for the initial trocar placement in the periumbilical region. Abdominal insufflation was performed. There were significant adhesions noted. A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular. After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially. The kidney was able to be palpated within Gerota's fascia. The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter. The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction. The renal pelvis was also identified and dissected free. There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes. We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open. An incision was made from the right upper quadrant port extending towards the midline. This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum. A Bookwalter retractor was placed. The renal pelvis and the ureter were again identified. Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery. The tissue was sent down to Pathology for analysis. Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted. Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place. The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue. At this point, the indwelling double-J ureteral stent was removed. At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed. This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated. The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture. At this point, a double-J stent was placed with a guidewire down into the bladder. The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture. Renal sinus fat was then placed around the anastomosis and sutured in place. Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue. This was repaired with horizontal mattress sutures #2-0 Vicryl. FloSeal was placed over this and the renal capsule was placed over this. A good hemostasis was noted. A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis. The initial trocar incision was closed with #0 Vicryl suture. The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia. The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture. The skin edges were then closed with staples. Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator. We placed the patient on IV antibiotics and pain medications. We will obtain KUB and x-rays for stent placement. Further recommendations to follow.surgery, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,

S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet.,soap / chart / progress notes, painful left foot, lesions, plantar, metatarsal head, hyperkeratotic lesion, toenail, nail matrix, metatarsal, metatarsal heads, foot, painful

PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.surgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

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

She was evaluated this a.m. and was without any significant clinical change. Her white count has been improving and down to 12,000. A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change. There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications. She states that the methadone did not work for her. She was "immune" to oxycodone. She had been on tramadol before and was placed back on that. There was some question that this may have been causing some dizziness. She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon. He had a box of her pain medications. It is unclear whether she took a bunch of these or precisely what happened. I was contacted that she was less responsive. She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain. The nurse found her and was unable to arouse her at this point. There was a concern that she had taken some medications from home. She was given Narcan and appeared to come around some. Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m. Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity. With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted. A chest x-ray was obtained at this time. An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU. We will continue the IV Zosyn. Respiratory protocol with respiratory management. Continue alprazolam p.r.n., but avoid if she appears sedated. We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being. I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission. At this juncture, she does not appear to need an intubation. Pending chest x-ray, she may require additional IV furosemide.cardiovascular / pulmonary, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE

PREOPERATIVE DIAGNOSES:,1. Torn anterior cruciate ligament, right knee.,2. Patellofemoral instability, right knee.,3. Possible torn medial meniscus.,POSTOPERATIVE DIAGNOSES:,1. Complete tear anterior cruciate ligament, right knee.,2. Complex tear of the posterior horn lateral meniscus.,3. Tear of posterior horn medial meniscus.,4. Patellofemoral instability.,5. Chondromalacia patella.,PROCEDURES PERFORMED:,1. Diagnostic operative arthroscopy with repair and reconstruction of anterior cruciate ligament using autologous hamstring tendon, a 40 mm bioabsorbable femoral pin, and a 9 mm bioabsorbable tibial pin.,2. Repair of lateral meniscus using two fast fixed meniscal repair sutures.,3. Partial medial meniscectomy.,4. Partial chondroplasty of patella.,5. Lateral retinacular release.,6. Open medial plication as well of the right knee.,ANESTHESIA:, General.,COMPLICATIONS:, None.,TOURNIQUET TIME:, 130 minutes at 325 mmHg.,INTRAOPERATIVE FINDINGS: , There was noted to be a grade-II chondromalacia patellofemoral joint. The patella was noted to be situated laterally past the lateral femoral condyle. There was a tear to the posterior horn of the medial meniscus within the white zone. There was a complex tear involving a horizontal cleavage component to the posterior horn of the lateral meniscus as well in the entire meniscus. There was a complete tear of the anterior cruciate ligament. The posterior cruciate ligament appeared intact. Preoperatively, she had a positive Lachman with a positive pivot shift test as well as increased patellofemoral instability.,HISTORY: , This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan.,PROCEDURE: ,On 09/11/03, she was taken to the operating room at ABCD General Hospital. She was placed supine on the operating table. General anesthetic was applied by the Anesthesiology Department. Tourniquet was placed on the proximal thigh and it was then placed in a knee holder. She was sterilely prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the lower extremity. Tourniquet was inflated to 325 mmHg. Longitudinal incision was made just medial to the tibial tubercle. The subcutaneous tissue was carefully dissected. Hemostasis was controlled with electrocautery. The tendons of gracilis and semitendinosus were identified and isolated, and then stripped off the musculotendinous junction. They were taken on the back table. The soft tissue debris was removed from the tendons. The ends of the tendons were sewn together using #5 Tycron whip type sutures. The tendons were measured on back table and found to be 8 mm as the most adequate size, they were then placed under tension on the back table. Stab incision was made in the inferolateral parapatellar region, through this camera was placed in the knee. The knee was inflated with saline solution and operative pictures were obtained. The above findings were noted. A second port site was initiated in the inferomedial parapatellar region. Through this, a probe was placed. Tear in the posterior horn medial meniscus was identified. It was resected using a meniscal resector. It was then further contoured using arthroscopic shaver. Attention was then taken to the lateral compartment. A partial meniscectomy was performed using the resector and the shaver. The posterior periphery of the lateral meniscus was also noticed to be unstable. A repair was then performed using two fasting fixed meniscal repair sutures to help anchor the meniscus around the popliteus tendon. There was noted to be excellent fixation. The shaver was then taken into the intrachondral notch. First a partial chondroplasty was performed on the patella to remove the loose articular debris as well as a partial synovectomy to the medial aspect of the patellar femoral joint. Next, the remnant of the anterior cruciate ligament was removed using the arthroscopic shaver and arthroplasty was then performed on the medial aspect of the lateral femoral condyle. Next, a tibial guide was placed through the anterior medial portal. A ___ pin was then placed up through the anterior incision entering the tibial eminence just anterior to the posterior cruciate ligament. This tibial tunnel was then drilled using 8 mm cannulated drill. Next, an over-the-top guide was then placed at approximately the 11:30 position. A ____ pin was then placed into the femur and 8 mm drill was then used to drill this femoral tunnel approximately 35 mm. Next the U shape guide was placed through tibial tunnel into the femur. A pin was then placed through the distal femur from lateral to medial, through the U-shaped guide a puller wire was then passed through the distal femur. It was then pulled out through the tibial tunnel using the You-shaped guide. The tendon was then placed around the wire. The wire was pulled back up through the tibial into the femoral tunnel. A 40 mm bioabsorbable pin was then placed through the femoral tunnel securing the hamstring tendons. Attention was then pulled through the tibial tunnel. The knee was cycled approximately 20 times. A 9 mm bioabsorbable screw was then placed through the tibial tunnel fixating the distal aspect of the graft. There was noted definite fixation of the graft. There was no evidence of impingement either in full flexion or full extension. The knee was copiously irrigated and it was then suctioned dry. A longitudinal incision was made just medial to the patellofemoral joint. Soft tissues were carefully dissected and the medial retinaculum was incised along with the incision. Following this, a release of lateral retinaculum was performed using a knife to further release the patellofemoral joint and allow further medial plication. The medial retinaculum was then plicated using #1 Ethibond sutures and then oversewn with #0 Vicryl suture. The subcuticular tissues were reapproximated with #2-0 Vicryl simple interrupted sutures followed by a #4-0 PDS running subcuticular stitch. She was placed in a DonJoy knee immobilizer. The tourniquet was deflated. It was noted the lower extremity was warm and pink with good capillary refill. She was transferred to the recovery room in apparent stable and satisfactory condition. Prognosis for this patient is guarded. She will be full weightbearing on the lower extremity using the knee immobilizer locked in extension. She may remove her dressing two to three days, however, follow back in the office in 10 to 14 days for suture removal. She will require one to two more physical therapy to help regain motion and strength to the lower extremity.

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home.neurosurgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,

PREOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left back skin nevus 2 cm.,2. Right mid back skin nevus 1 cm.,3. Right shoulder skin nevus 2.5 cm.,4. Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY: ,Pending.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, Consent was obtained. The areas were prepped and draped and localized in the usual manner. First attention was drawn to the left back. An elliptical incision was made with a 15-blade scalpel. The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse. After dissection, the skin was undermined. Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back. The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors. Afterwards, the skin was approximated using 4-0 nylon interrupted sutures. Next, attention was drawn to the shoulder lesion. It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin. The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture. Skin was closed with 4-0 nylon suture, interrupted. Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. Please refer to separate operative report for details. The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.surgery, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,

PREOPERATIVE DIAGNOSIS:, Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:, Same.,OPERATION:,pain management, chassaignac's tubercle, horner's sign, stellate ganglion block, sheath, vertebral, stellate, ganglion, cervical, block,

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.nan

PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. Bipolar electrocautery was used to maintain meticulous hemostasis. I then performed an antebrachial fasciotomy proximally. I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. Great care was taken with placement. A good plane was positively identified. I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me. I had my thumb on the distal aspect of the transverse carpal ligament. I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. I pulled back and cut and partially tightened the transverse carpal ligament. I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. I then checked to make sure this was properly performed and then cut the proximal aspect. I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time. Great care was taken and at no point was there any longitudinal structure cut. Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut. Following this, I irrigated and closed the skin. The patient was dressed and sent to the recovery room in good condition.orthopedic, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament

PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications.surgery, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,

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 & 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.radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,

PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 39 and 1/7th weeks.,2. Previous cesarean section, refuses trial of labor.,3. Fibroid uterus.,4. Oligohydramnios.,5. Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:, Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:, General.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, 1200 cc.,FLUIDS:, 2700 cc.,URINE:, 400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS: ,Placenta, cord gases and cord blood.,INDICATIONS: ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions. She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm. A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally. There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained. The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery. She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this. After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered. She was then prepped and draped in the normal sterile fashion. Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered. Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife. The fascia was incised in the midline with a second knife. This incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps. It was then dissected in the midline with Mayo scissors. The inferior aspect of this incision was then addressed in a similar manner. The rectus muscles were then separated in the midline with a hemostat. The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly. Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors. This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly. Next, the bladder blade was placed. The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors. This incision was extended laterally in both directions and a bladder flap was created digitally. The bladder blade was then reinserted. Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife. Next, the uterine incision was extended laterally in both directions with the banded scissors. Next, the infant's head and body were delivered without difficulty. There was multiple section on the abdomen. The cord was clamped and cut. Section of cord was collected for gases and the cord blood was collected. Next, the placenta was manually extracted. The uterus was exteriorized and cleared of all clots and debris. The edges of the uterine incision were then identified with Allis _______ clamps. The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis. One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid. After several minutes of observation, the hematoma was seem to be non-expanding. The uterus was replaced in the abdomen. The uterine incision was reexamined and seem to be continuing to be hemostatic. The pelvic gutters were then cleared of all clots and debris. The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion. The peritoneum was then closed with #0 Vicryl in a running fashion. The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch. The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x3. The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.nan

PREOPERATIVE DIAGNOSIS:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.surgery, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,

DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT: ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS: ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW: ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.nan

CHIEF COMPLAINT:, Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:, This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day. Also, history of chronic diverticulitis with recent bouts. The patient has been doing well, seen in my office at the end of December for complete physical examination. I had ordered a stress test for him, then delayed due to a family illness. However, denies any chest pain or chest tightness with exertion. The patient was doing well. He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. The patient's pain resolved. He was given nitroglycerin in the emergency room drawing his blood pressure 67/32. Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink.,PAST MEDICAL HISTORY:, Remarkable for tonsillectomies.,MEDICATIONS:, Synthroid and Lipitor.,ALLERGIES:, PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:, Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. He is afebrile.,GENERAL: He is well-developed, well-nourished white male, in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular movements were intact. Throat was clear.,NECK: Supple. There is no organomegaly or thyromegaly. Carotids are +2 without bruits.,CHEST: Lungs are clear to auscultation and percussion.,CV: Without any murmurs or gallops.,ABDOMEN: Soft. There is no hepatosplenomegaly. Bowel sounds are active. No tenderness.,EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses 2+.,NEUROLOGICAL: Intact. Motor exam is 5/5.,LABORATORY STUDIES:, EKG is within normal limits, good sinus rhythm. His axis is somewhat leftward. CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent.,2. Hypercholesterolemia.,3. Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered. His chest pain unit protocol for the stress thallium that will be done in the morning. If test is negative, we will discharge home. If positive, we will consult Cardiology. The patient requests Dr. ABC.nan

HISTORY:, I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY: ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change. She is currently 180 pounds.,PAST SURGICAL HISTORY:, Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY: ,The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally. No nystagmus.,EARS: During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position. No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice. No evidence of any orthostatic hypotension was noted during the exam. Tympanic membranes were noted to be intact. No signs of middle ear effusion or ear canal inflammation.,NOSE: The patient appears congested. Turbinate hypertrophy is noted. There are no signs of any acute sinusitis. Septum is midline, slightly deviated to the left.,THROAT: There is clear postnasal drip. Oral hygiene is good. No masses or lesions noted. Both vocal cords move well to midline.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION: ,1. Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2. Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3. Inferior turbinate hypertrophy.,4. Nasal septum deformity.,RECOMMENDATIONS:, An ENG was ordered to evaluate vestibular function. She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening. A Medrol Dosepak was prescribed as directed. The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended. After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations. In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.nan

CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was used. For further details of IV sedation and infusion, please refer to anesthesia notes. The patient was able to respond appropriately throughout the procedure. * Fluoroscopy was used to identify the appropriate anatomy. The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:, The patient was laid supine. Oblique placement was achieved by placing pillow below the shoulder and turning the head. The C# neural foramina was identified by counting down from the C2-3 foramen. The external carotid artery was marked off by palpation. The neck was aseptically prepared. 1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C# neural foramen under fluoroscopic control. The posterior inferior edge of the foramen bone was contacted. The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters. Care was taken to remain in the posterior inferior edge of the foramen. Positioning was checked by AP view, in which the needle tip extended no further medially than the midpoint of the adjacent pedicle. 1 mL of contrast was used to confirm position under fluoroscopy after aspiration. Acceptable dye pattern was seen. Subsequent 1 mL of 1% lidocaine was injected after aspiration and the patient was monitored. No adverse affects with 1% lidocaine were noted and subsequently 1 mL of Celestone was injected. Compression bandage was applied to the neck and no complications were noted.,POSTPROCEDURE EVALUATION:, After a 30-minute recovery period, during which no complications were noted, the patient was discharged home. Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95% with no respiratory distress observed.pain management, nerve root block, 1% lidocaine, asa monitors, cervical selective nerve root block, fluoroscopy, iv sedation, nerve root, oblique, selective nerve root, carotid artery, foramen, neural foramina, edge of the foramen, selective nerve root block, cervical,

TITLE OF OPERATION: ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY: ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery. Risks, benefits, alternatives of the procedures were discussed in great detail with the patient. Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other. The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table. After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube. The eyes were then tacked with Tegaderm. The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately. Essentially a 7 cm incision was employed in the lower skin crease of the neck. A 1% lidocaine with 1:100,000 epinephrine were given. Shoulder roll was applied. The patient prepped and draped in a sterile fashion. A 15-blade was used to make the incision. Subplatysmal flaps were raised to the thyroid notch and sternal respectively. The strap muscles were separated in the midline. As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side. The sternothyroid muscle was transected horizontally. Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline. Veins in this area and the pretracheal region were ligated with a harmonic scalpel. Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe. Again this was very firm in nature. The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel. The inferior and superior parathyroid glands were protected. Recurrent laryngeal nerve was identified in the tracheoesophageal groove. This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch. This was followed superiorly. The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea. A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side. There was significant amount of thyroid tissue that was very firm. Multiple nodules were appreciated. In a similar fashion, the capsule was dissected. The superior and inferior parathyroid glands protected and preserved. The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule. Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery. The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization. A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea. The entire thyroid specimen was then removed, marked with a stitch upon the superior pole. The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled. The parathyroid glands appeared to be viable. Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides. The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated. The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon. The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin. The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle. The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition. Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.endocrinology, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy

PREOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES:,1. Carotid artery occlusive disease.,2. Peripheral vascular disease.,OPERATIONS PERFORMED:,1. Bilateral carotid cerebral angiogram.,2. Right femoral-popliteal angiogram.,FINDINGS: , The right carotid cerebral system was selectively catheterized and visualized. The right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted. Likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,The left carotid cerebral system was selectively catheterized and visualized. The cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present. The intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,Visualization of the right lower extremity showed no significant disease.,PROCEDURE: , With the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,The common femoral artery was punctured in a routine retrograde fashion and a 5-French introducer sheath was advanced under fluoroscopic guidance. A catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,Following completion of the above, the catheter and introducer sheath were removed. Heparin had been initially given, which was reversed with protamine. Firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile Coverlet dressing and sandbag compression.,The patient tolerated the procedure well throughout.neurology, femoral-popliteal angiogram, carotid cerebral angiogram, internal carotid artery, carotid artery, angiogram, carotid, cerebral, artery,

HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE: ,After sedation and local Xylocaine 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 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,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 injection in the descending aorta.,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 normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X.,surgery, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization

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.radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,

PREOPERATIVE DIAGNOSIS:, Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:, General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheotomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition.cardiovascular / pulmonary, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,