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INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:, Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1. The patient exercised for 3 minutes stopping due to fatigue. No chest pain.,2. Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. Blood pressure rose from 150/88 to 210/100. There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL: ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images showed decreased uptake in the anterior wall. However the apex is spared of this defect. There is no significant change between rest and stress images. The sum score is 0.,2. The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1. No evidence of exercise induced ischemia at a high myocardial workload. This essentially excludes obstructive CAD as a cause of her elevated troponin.,2. Mild hypertensive cardiomyopathy with an EF of 48%.,3. Poor exercise capacity due to cardiovascular deconditioning.,4. Suboptimally controlled blood pressure on today's exam.cardiovascular / pulmonary, sinus rhythm, cardiac enzymes, abnormal ekg, stress test, elevated troponin, heart rate, blood pressure, radionuclide, chest, ekg, stress, ischemia

GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:nan

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.,dermatology, skin lesion, squamous cell carcinoma, punch biopsy,

IDENTIFYING DATA:, The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:, The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:, The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D. Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is "better now," but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:, The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon.nan

PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Blood loss anemia.,PROCEDURE PERFORMED:,1. Laparotomy.,2. Myomectomy.,ANESTHESIA: ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS: ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses. Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium. Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position. After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife. This was carried through the underlying layer of fascia with a second knife. The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly. It was then dissected in the middle with the Mayo scissors. The inferior aspect of this incision was addressed in a similar manner. The rectus muscles were separated in the midline bluntly. The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors. The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly. Next, the uterus was grasped bluntly and removed from the abdomen. The fundal fibroid was identified. It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels. 15 cc was injected. Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen. The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger. The fibroid was easily and bluntly dissected out. It was also grasped with Lahey clamp to prevent traction. Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse. The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed. At this point, several smaller fibroids were noticed along the endometrial surface of the uterus. Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size. These were also handed to the scrub tech. Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch. The uterus was seen to be completely hemostatic after closure. Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline. The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed. Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline. Then the fascia was closed with #0 Vicryl in a running fashion. Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion. The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately. After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.obstetrics / gynecology, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly,

EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:, Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:, There is reversal of the normal cervical curvature at the vertebral body heights. The intervertebral disk spaces are otherwise maintained. There is no prevertebral soft tissue swelling. The facets are aligned. The tip of the clivus and occiput appear intact. On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact. There is no evidence of a posterior element fracture. Included portions of the mastoid air cells appear clear. There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.radiology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct,

PREOPERATIVE/POSTOPERATIVE DIAGNOSES:,1. Severe tracheobronchitis.,2. Mild venous engorgement with question varicosities associated pulmonary hypertension.,3. Right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,PROCEDURE PERFORMED: , Flexible fiberoptic bronchoscopy with:,a. Right lower lobe bronchoalveolar lavage.,b. Right upper lobe endobronchial biopsy.,SAMPLES: , Bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,INDICATIONS: , The patient with persistent hemoptysis of unclear etiology.,PROCEDURE: , After obtaining informed consent, the patient was brought to Bronchoscopy Suite. The patient had previously been on Coumadin and then heparin. Heparin was discontinued approximately one-and-a-half hours prior to the procedure. The patient underwent topical anesthesia with 10 cc of 4% Xylocaine spray to the left nares and nasopharynx. Blood pressure, EKG, and oximetry monitoring were applied and monitored continuously throughout the procedure. Oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure. The patient was premedicated with 50 mg of Demerol and 2 mg of Versed. After conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx. There was minimal redundant oral soft tissue in the oropharynx. There was mild erythema. Clear secretions were suctioned.,Additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% Xylocaine was applied. Vocal cord motion was normal. The bronchoscope was then advanced through the larynx into the trachea. There was evidence of moderate inflammation with prominent vascular markings and edema. No frank blood was visualized. The area was suction clear of copious amounts of clear white secretions. Additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem. The bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe. There was significant amount of inflammation, induration, and vascular tortuosity in these regions. No frank blood was identified. No masses or lesions were identified. There was senile bronchiectasis with slight narrowing and collapse during the exhalation. The air was suctioned clear. The bronchoscope was withdrawn and advanced into the right main stem. Bronchoscope was introduced into the right upper lobe and each sub-segment was visualized. Again significant amounts of tracheobronchitis was noted with vascular infiltration. In the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this. The bronchoscope was removed and advanced into the right middle and right lower lobe. There was marked injection and inflammation in these regions. In addition, there was marked vascular engorgement with near frank varicosities identified throughout the region. Again, white clear secretions were identified. No masses or other processes were noted. The area was suctioned clear. A bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe. The bronchoscope was then withdrawn and readvanced into the right upper lobe. Endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained. Minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine. The area remained clear. No further hemorrhage was identified. The bronchoscope was subsequently withdrawn. The patient tolerated the procedure well and was stable throughout the procedure. No further hemoptysis was identified. The patient was sent to Recovery in good condition.cardiovascular / pulmonary, bronchoalveolar lavage, endobronchial biopsy, cytology, microbiology, tracheobronchitis, venous engorgement, varicosities, pulmonary hypertension, flexible fiberoptic bronchoscopy, fiberoptic bronchoscopy, lobe, bronchoalveolar, lavage, endobronchial, hemorrhage, oropharynx, vascular, bronchoscopy, biopsy, submucosal, bronchoscope

PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:, Primary cesarean section by low-transverse incision.,ANESTHESIA:, Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009. The patient began having prodromal symptoms 2 to 3 days prior to presentation. She was seen on 03/09/2007 and a nonstress test was performed. This revealed some spontaneous variable-appearing decelerations. She was given IV hydration. A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found. Therefore, she was admitted for further fetal monitoring and evaluation. She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated. She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute. Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion. This relieved the decelerations somewhat. However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations. Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery. These findings were reviewed with the patient and recommendation was made for cesarean section delivery. The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced. She was prepped and draped in the usual fashion for the procedure. After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall. This incision was carried down to the level of the fascia, which was also transversely incised. After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle. The rectus muscle was separated in midline exposing the peritoneum. The peritoneum was carefully grasped and elevated with hemostats. It was entered in an up and down fashion with Metzenbaum scissors. The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected. A thin lower uterine segment was noted. The vertex presentation was confirmed. The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall. Clear fluid was noted upon entering into the amniotic space. At 05:27, a term viable female infant was delivered up through the incision. She had spontaneous respirations. She was given bulb suctioning for clear fluid. Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending. The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes. Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity. A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis. The uterus was delivered up into the operative field. The endometrial cavity was swiped clean with a moist laparotomy pad. The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating. Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis. The uterine incision was noted to be hemostatic upon closure. The uterus was rotated forward, normal tubes and ovaries were noted on both sides. The uterus was then returned to its normal position of the abdominal cavity. The sponge and instrument count was performed for the first time at this point and found to be correct. The pelvis and anterior uterine space was then irrigated with saline solution. It was suctioned dry. A final check of the uterine incision confirmed hemostasis. The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture. The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline. The subcutaneous tissue was then irrigated and inspected. No active bleeding was noted. It was closed with a running length of 3-0 plain catgut suture. The skin was then approximated with surgical steel staples. The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic. The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition. The estimated blood loss through the procedure was 450 mL. The sponge and instrument counts were performed two more times during closure and found to be correct each time.surgery, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine,

TITLE OF OPERATION:,1. Austin-Akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2. Weil osteotomy with internal screw fixation, first right metatarsal.,3. Arthroplasty, second right PIP joint.,PREOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,POSTOPERATIVE DIAGNOSES:,1. Bunion deformity, right foot.,2. Dislocated second right metatarsophalangeal joint.,3. Hammertoe deformity, second right digit.,ANESTHESIA:, Monitored anesthesia care with 20 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS:, 60 minutes, a right ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,PREOPERATIVE INJECTABLES: ,1 g Ancef IV 30 minutes preoperatively.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, 5-0 Prolene, as well as two 16-mm partially treaded cannulated screws of the OsteoMed system, one 18-mm partially treaded cannulated screw of the OsteoMed system of the 3.0 size. One 10-mm 2.0 partially threaded cannulated screw of the OsteoMed system.,DESCRIPTION OF THE PROCEDURE: ,The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites. The right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmHg. The right foot was then prepped, scrubbed, and draped in a normal sterile technique. The right ankle tourniquet was then inflated. Attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,A lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint. Using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw. The same saw was used to perform the Austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal. The dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation. The capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal. Two wires of the OsteoMed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws. The wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy. The two screws from the 3.0 OsteoMed system were inserted over the wires using AO technique. One screw measured 16 mm, second screw measured 18 mm in length. Both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed. Fixation of the osteotomy was found to be excellent. The dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw. To improve the correction of the hallux abductus angle, an Akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally. Upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the OsteoMed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the OsteoMed 3.0 system. Upon insertion of the screw, using AO technique, the wire was removed. The screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe. Fixation of the osteotomy was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical. Range of motion of that joint was uninhibited. The area was flushed copiously with saline. Then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and Steri-Strips were used to reinforce the incision. Attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped and cauterized. The incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then Weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal. The capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,The 2.0 Osteo-Med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw. Upon insertion of the screw, using AO technique, the wire was then removed. Fixation of the osteotomy with 2.0 screw was found to be excellent. The second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced. Range of motion of the second right metatarsophalangeal joint was found to be excellent. Then, 3-0 Vicryl suture material was used to approximate the periosteal tissues. Then, 4-0 Vicryl was used to approximate the skin incision. Attention was then directed at the level of the PIP joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right PIP joint. The island of skin between the two semi-elliptical incisions was resected in toto. The dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the PIP joint. A capsulotomy and a medial and lateral collateral ligament release of the PIP joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed. Using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected. The area was copiously flushed with saline. The capsular and periosteal tissues were approximated with 2-0 Vicryl and 3-0 Vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe. A 5-0 Prolene was used to approximate the skin edges of the two semi-elliptical incisions. Correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical. At this time, the patient's three incisions were covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right ankle tourniquet was deflated, time was 60 minutes. Immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,The patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.orthopedic, austin-akin bunionectomy, weil osteotomy, internal screw fixation, first right metatarsal, metatarsophalangeal joint, hammertoe deformity, extensor digitorum longus, austin akin bunionectomy, threaded cannulated screw, semi elliptical incisions, ankle tourniquet, surgical neck, cannulated screws, pip joint, proximal phalanx, fixation, metatarsophalangeal, proximal, screw, metatarsal, osteotomy, austin, joint, tourniquet, osteomed, phalanx, incision,

HISTORY OF PRESENT ILLNESS:, Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound. She describes no drainage or erythema from her bottom. She is having good ostomy output. She does not describe any fevers, chills, nausea, or vomiting. The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy. She has been taking Percocet for this pain and it does work. She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain. She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds. This is a pleasant female in no acute distress. The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar. There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant. There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter. I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less. I have counseled her on refraining from soft drinks and fruit drinks. I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy. She also had questions about her occasional abdominal pain. I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain. I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain. The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery. This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping. I told her that I felt that this would continue to improve as it has done over the past two months since her surgery. I told her to continue doing hand exercises as she has been doing and this seems to be working for her. Overall, I think she has healed from her surgery and is doing very well. Again, her quality of life is significantly improved. She is happy with her performance. We will see her back in six months just for a general routine checkup and see how she is doing at that time.soap / chart / progress notes, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE

Assessment for peripheral vestibular function follows:,OTOSCOPY:, showed bilateral intact tympanic membranes with central Weber test and bilateral positive Rinne.,ROMBERG TEST:, maintained postural stability.,FRENZEL GLASSES EXAMINATION:, no spontaneous, end gaze nystagmus.,HEAD SHAKING:, No provocation nystagmus.,DIX-HALLPIKE:, showed no positional nystagmus excluding benign paroxysmal positional vertigo.,VESTIBULOCULAR REFLEX [HALMAGYI TEST]:, showed corrective saccades giving the impression of decompensated vestibular hypofunction.,IMPRESSION: , The patient was advised to continue her vestibular rehabilitation exercises and the additional medical treatment of betahistine at 24 mg dose bid. ,PLAN: ,Planned for electronystagmography to document the degree of vestibular hypofunction.,ent - otolaryngology, electronystagmography, hearing impairment, imbalance, tinnitus, hypofunction, nystagmus, vestibular, vertigo,

MULTISYSTEM EXAM,CONSTITUTIONAL: ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: ,The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: ,The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: ,The neck was supple. The thyroid gland was not enlarged by palpation.,RESPIRATORY: ,The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.,GU: , The scrotal elements were normal. The testes were without discrete mass. The penis showed no lesion, no discharge.,LYMPHATIC: ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL: ,The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.,NEUROLOGIC: ,Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

PREOPERATIVE DIAGNOSES:,1. Acute pain.,2. Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1. Acute pain.,2. Fever postoperatively.,3. Hemostatic uterine perforation.,4. No bowel or vascular trauma.,PROCEDURE PERFORMED:,1. Diagnostic laparoscopy.,2. Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:, None.,INDICATIONS: ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. The patient denied any nausea, vomiting or diarrhea. She does complain of some frequent urination. Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. The bilateral tubes and ovaries appeared normal. There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. There is no evidence of injury to the bowel or pelvic sidewall. The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered. The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. Veress needle was placed through this incision and the gas turned on. When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. A 11 mm trocar was then placed through this incision. The camera was placed with the above findings noted. A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. At this point, Dr. X was consulted. He performed a rigid sigmoidoscopy, please see his dictation for further details. There does not appear to be any evidence of colonic injury. The saline in the pelvis was then suctioned out using Nezhat-Dorsey. All instruments were removed. The 5 mm trocar was removed under direct visualization with excellent hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar removed. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief. Steri-Strips were then placed across the incision. The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct at the end of the procedure. The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.gastroenterology, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar,

PREOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES: ,1. Left chest actinic keratosis, 2 cm.,2. Left medial chest actinic keratosis, 1 cm.,3. Left shoulder actinic keratosis, 1 cm.,TITLE OF PROCEDURES: ,1. Excisional biopsy of left chest 2 cm actinic keratosis.,2. Two-layer plastic closure.,3. Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.,4. Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PROCEDURE: , All areas were prepped, draped, and localized in the usual manner. Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions. After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure. She tolerated this procedure very well, and postoperative care instructions were provided. She will follow up next week for suture removal. Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.surgery, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest

PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac. Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE: ,The patient was taken to the operating room and placed under general anesthesia. She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner. Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated. Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed. Laparoscope was inserted through the cannula and the pelvis was visualized. Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline. Incision sites were transilluminated and injected with Marcaine prior to cutting. Hulka manipulator was placed on the cervix. Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac. The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis. Some more lesions were noted above the left uterosacral ligament. Flame lesions were noted above the right uterosacral ligament. Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube. There was a somewhat leathery appearance to the ovaries. The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window. Pelvis was irrigated and all operative sites were hemostatic. No other abnormalities were visualized and all instruments were moved under direct visualization. Approximately 200 mL of fluid remained in the abdominal cavity. All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape. The patient was taken to the recovery in stable condition.obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation

ADMITTING DIAGNOSIS:, Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1. Intrauterine pregnancy at term with previous cesarean.,2. Desired sterilization.,3. Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09. Pregnancy was uncomplicated. She opted for a scheduled elective C-section and sterilization without any trial of labor. All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:, SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:, She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL: An alert gravid woman in no distress.,ABDOMEN: Gravid, nontender, non-irritable, with an infant in the vertex presentation. Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE: ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9. There was normal placenta, normal pelvic anatomy. There was 600 cc estimated blood loss. Patient recovered uneventfully from her anesthesia and surgery. She was able to ambulate and void. She tolerated regular diet. She passed flatus. She was breast-feeding. Postoperative hematocrit was 31. On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain. Paxil for postpartum depression. She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.obstetrics / gynecology, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy,

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.orthopedic, hand pain, pain, hand, metacarpals

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

PREOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:, Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1. Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2. Microscope.,3. Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4. Eagle titanium plate from C3 to C6.,5. Jackson-Pratt drain placement.,6. Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: ,None.,COUNTS: , Correct.,SPECIMENS SENT: ,None.,CLINICAL HISTORY: ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling. He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy. I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly. The patient had worst disease at level C3-C4, C4-C5, and C5-C6. The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side. I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall. Conservative management was not an option. The patient was preoped and consented, and was medically cleared. I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family. The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient. An informed consent was obtained from the patient as such. He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the OR, intubated, and given a general anesthetic. Intubation was done under C-spine precautions. The patient received preoperative vancomycin and Decadron. He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped. All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine. Prominent osteophyte at C5-C6 was noted, lesser at C4-C5. Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went. I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord. Worst findings at C3-C4 followed C5-C6 and then C4-C5. Excellent thecal sac decompression was achieved and foraminal decompression was also achieved. With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant. This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time. I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis. This took literally half-an-hour to an hour and added to the complexity and difficulty of this case. Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution. These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position. Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6. Fourteen millimeter screws were used; all the screws were tightened and torqued. The patient's bone quality was poor, but the screws did torque appropriately. I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar. Decision was made to start the closure. So, I closed the platysma with 3-0 Vicryl and used staples for the skin. A simple Primapore or Medpore dressing was applied. The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side. He had done well from the surgery. Blood loss was 350 cc. All instrument, needle, and sponge counts were correct. No complications, no change in intraoperative monitoring. No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis. The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity. I will keep him on Decadron and keep the collar on. I do not think there is need for halo rest. We will be obtaining formal C-spine films in the morning. Prognosis is guarded but favorable at this time.nan

PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,IMPLANTS USED:,1. DePuy Ultima calcar stem, size 3 x 45.,2. Bipolar head 28 x 43.,3. Head with +0 neck length.,4. Distal centralizer and cement restrictor.,5. SmartSet antibiotic cement x2.,ANESTHESIA: , General.,NEEDLE AND SPONGE COUNT: , Correct.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , 300 mL.,SPECIMEN: , Resected femoral head and tissue from the fracture site as well as the marrow from the canal.,FINDINGS: ,On exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. The lesser trochanter was intact. The fracture site was noted to show abnormal pathological tissue with grayish discoloration. The quality of the bone was also pathologically abnormal with soft trabecular bone. The abnormal pathological tissues were sent along with the femoral head to pathology for assessment. Articular cartilage of the acetabulum was intact and well preserved.,INDICATION: , The patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. She denied any history of fall or trauma. The presentation was consistent with pathological fracture pending tissue assessment. Indication, risks, and benefits were discussed. Treatment options were reviewed. No guarantees have been made or implied.,PROCEDURE: ,The patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. The left lower extremity was prepped and draped in a standard sterile fashion. Time-out procedure was called. Antibiotics were infused.,A standard posterolateral approach was made. Subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. This was then incised along the line of the incision. Hemostasis was achieved. Charnley retractor was positioned. The trochanter was intact. The gluteus medius was well protected with retractor. The piriformis and minimus junction was identified. The minimus was also reflected along with the medius. Using Bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. Similarly, L-shaped capsulotomy was performed. A #5 Ethibond was utilized to tag the piriformis and the capsule for late repair. Fracture site was exposed. The femoral neck fracture was noted to be very low-lying basicervical type. Femoral head was retrieved without any difficulty with the help of a corkscrew. The head size was measured to be 43 mm. Bony fragments were removed. The acetabular socket was thoroughly irrigated. A 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. The specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. This was sent to the pathology. The fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. An L-shaped osteotomy was performed in order to accept the calcar prosthesis. The basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. There was no calcar superior to the lesser trochanter. The L-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. Hemostasis was achieved. Now, the medullary canal was entered with a canal finder. The fracture site was well exposed. Satisfactory lateralization was performed. Attention was for the reaming process. Using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. At this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. Appropriate anteversion was positioned. The anteversion was marked with a Bovie to identify subsequent anteversion during implantation. The bony edges were trimmed. The calcar implant with 45 mm neck length was fit in the host femur very well. There was no evidence of any subsidence. At this point, trial reduction was performed using a bipolar trial head with 0 neck length. The relationship between the central femoral head and the greater trochanter was satisfactory. The hip was well reduced without any difficulty. The stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. The shuck was less than 1 mm. Leg length was satisfactory in reference to the contralateral leg. Stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. Similarly, keeping the leg completely adducted, I was able to internally rotate the hip to 45 degrees. After verifying the stability and range of motion in all direction, trial components were removed. The canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. At this point, 2 batches of SmartSet cement with antibiotics were mixed. The definitive Ultima calcar stem size 3 with 45 mm calcar body was selected. Centralizer was positioned. The cement restrictor was inserted. Retrograde cementing technique was applied once the canal was dried. Using cement gun, retrograde cementing was performed. The stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. The excess cement was removed with the help of a curette and Freer elevator. All the cement debris was removed.,Attention was now placed for the insertion of the trial femoral head. Once again, 0 neck length trial bipolar head was inserted over the trunnion. It was reduced and range of motion and stability was satisfactory. I also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. The hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. There was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. I also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. At this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. Range of motion and stability was as above. Now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. This was repaired to the trochanteric insertion using #5 Ethibond and suture plaster. Satisfactory reinforcement was achieved with the #5 Ethibond. The wound was thoroughly irrigated. Hemostasis was achieved. The fascia was closed with #1 Vicryl followed by subcutaneous closure using 2-0 Vicryl. The wound was thoroughly washed and a local injection with mixture of morphine and Toradol was infiltrated including the capsule and the pericapsular structures. Skin was approximated with staples. Sterile dressings were placed. Abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. There were no intraoperative complications noted.nan

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 26 year old with a history of instability. Examination was preformed on 12/20/2005.,FINDINGS:,There is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,Normal infraspinatus and subscapularis tendons.,Normal long biceps tendon within the bicipital groove. There is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. Biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,There is a very large Hill-Sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). This is associated with a large inferior bony Bankart lesion that measures approximately 15 x 18mm in AP and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). There is medial and inferior displacement of the fragment. There are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (These are too numerous to count.) There is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated HAGL lesion (series #105 images #5-10).,Normal superior glenohumeral ligament.,There is no SLAP tear.,Normal acromioclavicular joint without narrowing of the subacromial space.,Normal coracoacromial, coracohumeral and coracoclavicular ligaments.,There is fluid in the glenohumeral joint and biceps tendon sheath.,IMPRESSION:,There is a very large Hill-Sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous Bankart lesion.,There are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,There is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,orthopedic, inferior and middle glenohumeral, biceps tendon, partial tearing, glenohumeral ligaments, mri, shoulder, ligament, ligaments, biceps, humeral, glenohumeral, tear, tendons

FAMILY HISTORY:, Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:, She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed. She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:, Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:, In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS: ,HEENT: For headaches and sore throat. Musculoskeletal: She is right handed with joint pain, stiffness, and decreased range of motion. Cardiac: For heart murmur. GI: Negative and noncontributory. Respiratory: Negative and noncontributory. Urinary: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. Genital: Negative and noncontributory. She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall. Current weight is 132 pounds, weight one year ago was 126 pounds. BP is 122/68. On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. General, a well-developed and well-nourished female in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth good dentition. Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movement. Cranial nerve VIII, hearing intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance. Cardiac, regular rate and rhythm. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Peripheral vascular, no cyanosis, clubbing, or edema. Examination of the low back reveals some mild paralumbar spasms. She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature. She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation. Deep tendon reflexes are 2+ bilateral knees and ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Straight leg raising is negative bilaterally. Strength on manual exam is 5/5 and equal bilateral lower extremity. She is able to ambulate on her toes and her heels without any difficulty. She is able to get up standing on one foot on to the toes. She does have some difficulty getting up on to her heels when standing on one foot. She has trouble with this on the left and right. She complains of increased pain while doing this as well. She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left. Sensation is intact. She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout. At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged. At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear. This could represent a facet synovial cyst. This is lateral to the facet. She does not have x-rays for review. She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1 Do nothing.,2. Conservative therapies.,3. Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays. We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that. After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing. All questions and concerns were addressed. If she should have any further questions, concerns, or complications, she will contact our office immediately. Otherwise, we will see her as scheduled. Case was reviewed and discussed with Dr. L.orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia,

PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2. Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure. The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region. This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease. The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion. The area was dressed with antibiotic ointment and then a Peri-Pad. The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes. Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex. Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized. Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple. At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple. When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft. At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola. At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic. The areolar skin graft was pie crusted. Then, at this point, the area of areola was dressed with silicone gel sheeting. A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position. Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made. The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out. When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision. Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola. The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.cosmetic / plastic surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, areolar reconstruction, skin graft, graft, nipple, areolar, breast

PREOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room. The abdominal contents were within normal limits. The aorta was of normal size and consistency consistent with arteriosclerosis. A 16x8 mm Gore-Tex graft was placed without difficulty. The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution. A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area. Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges. Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia. Hemostasis was obtained with electrocautery. The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery. Mild adhesions were lysed. The omentum was freed. The small and large intestine were run with no evidence of abnormalities. The liver and gallbladder were within normal limits. No abnormalities were noted. At this point, the Bookwalter retractor was placed. NG tube was placed in the stomach and placed on suction. The intestines were gently packed intraabdominally and laterally. The rest of the peritoneum was then opened. The aorta was cleared, both proximally and distally. The left iliac was completely occluded. The right iliac was to be cleansed. At this point, 5000 units of aqueous heparin was administered to allow take effect. The aorta was then clamped below the renal arteries and opened in a longitudinal fashion. A single lumbar was ligated with #3-0 Prolene. The inferior mesenteric artery was occluded intraluminally and required no suture closure. Care was taken to preserve collaterals. The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion. Last stitch was tied. Hemostasis was excellent. The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis. At this point, strong pulses were present within the graft. The limbs were vented and irrigated. Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin. The grafts were then brought through these, care being taken to avoid twisting of the graft. At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed. Hemostasis was excellent. The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors. The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion. Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied. Flow was initially restored proximally then distally with good results. Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally. The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis. The last stitch was tied. Strong pulses were present within the artery and graft itself. At this point, 25 mg of protamine was administered. The wounds were irrigated with antibiotic solution. The groins were repacked. Attention was then returned to the abdomen. The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present. The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft. The intraabdominal contents were then allowed to resume their normal position. There was no evidence of ischemia to the large or small bowel. At this point, the omentum and stomach were repositioned. The abdominal wall was closed in a running single layer fashion using #1 PDS. The skin was closed with skin staples. The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips. The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well. Sponges and instrument counts were correct. Estimated blood loss 900 cc.cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,

CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. At this point, the Hospitalist Service was contacted for admission. The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure. The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female. Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. Birthweight was 7 pounds 4 ounces at Community Hospital. The mother did have a repeat C-section. There is no rupture of membranes or group B strep status. The prenatal care began in the second month of pregnancy and was otherwise uncomplicated. Mother denies any sexual transmitted diseases or other significant illness. The patient was discharged home on day of life #3 without any complications.,ALLERGIES:, No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother. She has 2 older male siblings. All were reported good health. Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS: ,GENERAL: The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. Mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,HEENT: Denies any significant nasal congestion or cough. ,RESPIRATORY: Denies any difficulty breathing or wheezing. ,CARDIOVASCULAR: As per above. GI: No history of any persistent vomiting or diarrhea. ,GU: Denies any decreased urinary output. ,MUSCULOSKELETAL: Negative. ,NEUROLOGICAL: Negative. ,SKIN: Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is examined in her room, our next floor. She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS: Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT: Normocephalic. The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. The anterior fontanelle is soft and flat. Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. There is also some mild posterior rotation of the ears. Oropharynx, mucous membranes are pink and moist. There is a slightly high arched palate.,NECK: Significant for possible mild reddening of the neck.,LUNGS: Significant for perihilar crackles. Mild tachypnea is noted. O2 saturations are currently 97% on room air. There is mild intercostal retraction.,CARDIOVASCULAR: Heart has regular rate and rhythm. Peripheral pulses are only 1+. Capillary refills less than 3-4 seconds.,EXTREMITIES: Slightly cool to touch. There is 2-3/6 systolic murmur along the left sternal border. Does radiate to the axilla and to the back.,ABDOMEN: Soft, slightly distended, but nontender. The liver edge is palpable 4 cm below right costal margin. The spleen tip is also palpable.,GU: Normal female external genitalia is noted.,MUSCULOSKELETAL: The patient has poor fat deposits in her extremities. Strength is only 2/4. She had normal number of fingers and toes.,SKIN: Significant for slight mottling. There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4. Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1. Failure-to-thrive.,2. Significant murmur and patent ductus arteriosus.,3. Congestive heart failure.,PLAN: ,At present, we are going to admit and monitor closely tonight. We will get a chest x-ray and start Lasix at 1 mg/kg twice daily. We will also get a CBC and check a blood culture and further workup as necessary.nan

HEENT:, No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:, No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:, No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.general medicine, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,

REASON FOR CONSULTATION:, Perioperative elevated blood pressure.,PAST MEDICAL HISTORY:,1. Graves disease.,2. Paroxysmal atrial fibrillation, has been in normal sinus rhythm for several months, off medication.,3. Diverticulosis.,4. GERD.,5. High blood pressure.,6. Prostatic hypertrophy, status post transurethral resection of the prostate.,PAST SURGICAL HISTORY: , Bilateral inguinal hernia repair, right shoulder surgery with reconstruction, both shoulders rotator cuff repair, left knee arthroplasty, and transurethral resection of prostate.,HISTORY OF PRESENTING COMPLAINT: ,This 71-year-old gentleman with the above history, underwent laser surgery for the prostate earlier today. Before surgery, the patient's blood pressure was 181/107. The patient received IV labetalol. Blood pressure improved, but postsurgery, the patient's blood pressure went up again to 180/100. Currently, blood pressure is 158/100, goes up to 155 systolic when he is talking. On further questioning, the patient denies shortness of breath, chest pain, palpitations, or dizziness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No recent fever or general malaise.,ENT: Unremarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: No chest pain.,GASTROINTESTINAL: No nausea or vomiting.,GENITOURINARY: The patient has prostatic hypertrophy, had laser surgery earlier today.,ENDOCRINE: Negative for diabetes, but positive for Graves disease.,MEDICATIONS: ,The patient takes Synthroid and aspirin. Aspirin had been discontinued about 1 week ago. He used to be on atenolol, lisinopril, and terazosin, both of which have been discontinued by his cardiologist, Dr. X several months ago.,PHYSICAL EXAMINATION:,GENERAL: A 71-year-old gentleman, not in acute distress.,CHEST: Clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: There is no swelling.,NEUROLOGICAL: The patient is alert and oriented x3. Examination is nonfocal.,ASSESSMENT AND PLAN:,1. Perioperative hypertension. We will restart lisinopril at half the previous dose. He will be on 20 mg p.o. daily. If blood pressure remains above systolic of 150 within 3 days, the patient should increase lisinopril to 40 mg p.o. daily. The patient should see his primary physician, Dr. Y in 2 weeks' time. If blood pressure, however, remains above 150 systolic despite 40 mg of lisinopril, the patient should make an appointment to see his primary physician in a week's time.,2. Prostatic hypertrophy, status post laser surgery. The patient tolerated the procedure well.,3. History of Graves disease.,4. History of atrial fibrillation. The patient is in normal sinus rhythm.,DISPOSITION: ,The patient is stable to be discharged to home. Nurse should observe for 1 hour after lisinopril to make sure the blood pressure does not go too low.nan

PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:, Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes. Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain. Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE: ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position. The patient was then placed under general anesthesia. A local block was then injected into the third ray of the left foot. The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique. The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated. Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace. The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures. Identification of the neuroma was made following plantar flexion of the digits. It was grasped with a hemostat and it was dissected in toto and removed. It was then sent to pathology. The area was then flushed with copious amounts of sterile saline. Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin. Steri-Strips were then placed over that area. A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot. The tourniquet was then released. Good flow was noted to return to all digits. The patient did tolerate the procedure well. He left the operating room with all vital signs stable and neurovascular status intact. The patient went to the recovery. The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain. The patient will follow up with me in approximately 4 days for dressing change.surgery, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,

IDENTIFYING DATA:, This is a 40-year-old male seen today for a 90-day revocation admission. He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time. He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998.,MEDICATIONS: , Listed as Invega and Risperdal.,ALLERGIES: , None known to medications.,PAST MEDICAL HISTORY: ,The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,FAMILY HISTORY: , Listed as unknown in the chart as far as other psychiatric illnesses. The patient himself states that his parents are deceased and that he raised himself in the Philippines.,SOCIAL HISTORY:, He immigrated to this country in 1984, although he lists himself as having a green card still at this time. He states he lives on his own. He is a single male with no history of marriage or children and that he had high school education. His recreational drug use in the chart indicates that he has had a history of methamphetamines. The patient denies this at this time. He also denies current alcohol use. He does smoke. He is unable to tell me of any PCP. He is in counseling service with his case manager being XYZ.,LEGAL HISTORY: , He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time.,OBJECTIVE FINDINGS: ,VITAL SIGNS: , Blood pressure is 125/75. His weight is 197 with height 5 feet 4 inches.,GENERAL:, He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications. He does not endorse any voices at this time.,HEENT: , His head exam is normal with normal scalp. HEENT is unremarkable. Pupils equal and reactive to light and accommodation. TMs are normal.,NECK:, Unremarkable with no masses or tenderness.,CARDIOVASCULAR:, Normal S1 and S2. No murmurs.,LUNGS:, Clear.,ABDOMEN: ,Negative with no scars.,GU: ,Not done.,RECTAL:, Not done.,DERM:, He does have a scarring of acne lesions, both face and back.,EXTREMITIES:, Otherwise negative.,NEUROLOGIC: , Cranial nerves II through X normal. Reflexes are normal and gait is unremarkable.,LABORATORY DATA: , His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2. Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids.,ASSESSMENT: , History of hyperlipidemia with elevated triglycerides. We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.nan

ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS: ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY: ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE: ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period. On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs. She required intravenous narcotics for pain control. She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control. The wound was clean and dry. The drain was removed. She was instructed to follow up in the surgical office within one week after discharge. She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.general medicine, nodular, symptomatic thyroid goiter, thyroidectomy, goiter,

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

PAST MEDICAL HISTORY: ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer. There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins. The fetal biometry of twin A is as follows. The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day. The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g. The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g. The following structures were seen as normal on the fetal anatomical survey. The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta. Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day. There is like gender and a single placenta. One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications. We focused our discussion today on the association of twin pregnancy with preterm delivery. We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation. We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation. These are the twins which we have the most concern regarding the long-term prospects of prematurity. We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction. We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth. We discussed the need for frequent office visits to screen for preeclampsia. We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids. I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient. I did review all of the above findings and recommendations with the patient today at the time of her visit. Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes.obstetrics / gynecology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound,

PREOPERATIVE DIAGNOSIS:, Nonpalpable right undescended testis.,POSTOPERATIVE DIAGNOSIS: , Nonpalpable right undescended testis with atrophic right testis.,PROCEDURES: , Examination under anesthesia, diagnostic laparoscopy, right orchiectomy, and left testis fixation.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUID RECEIVED: ,250 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMEN:, The tissue sent to Pathology was right testicular remnant.,ABNORMAL FINDINGS:, Closed ring on right with atrophic vessels going into the ring and there was obstruction at the shoulder of the ring. Left had open appearing ring but the scrotum was not filled and vas and vessels going into the ring.,INDICATIONS FOR OPERATION: , The patient is a 2-year-old boy with a right nonpalpable undescended testis. The plan is for evaluation and repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, a caudal block was placed. The patient was placed in supine position and examined. The left testis well within scrotum. The right was again not palpable despite the patient being asleep with multiple attempts to check.,The patient was then sterilely prepped and draped. An 8-French feeding tube was then placed within his bladder through the urethra and attached to the drainage. We then incised the infraumbilical area once he was sterilely prepped and draped, with 15 blade knife, then using Hasson technique with stay stitches in the anterior and posterior rectus fascia sheath of 3-0 Monocryl. We entered the peritoneum with the 5-mm one-step system. We then used the short 0-degree lens for laparoscopy. We then insufflated with carbon dioxide insufflation to pressure of 12 mmHg. There was no bleeding noted upon evaluation of the abdomen and again the findings were as mentioned with closed ring with vas and vessels going to the left and vessels and absent vas on the right where the closed ring was found. Because there was no testis found in the abdomen, we then evacuated the gas and closed the fascial sheath with the 3-0 Monocryl tacking sutures. Then skin was closed with subcutaneous closure of 4-0 Rapide. A curvilinear upper scrotal incision was made on the right with 15 blade knife and carried down through the subcutaneous tissue with electrocautery. Electrocautery was used for hemostasis. A curved tenotomy scissor was used to open the sac. The tunica vaginalis was visualized and grasped and then dissected up towards external ring. There was no apparent testicular tissue. We did remove it, however, tying off the cord structure with a 4-0 Vicryl suture and putting a tagging suture at the base of the tissue sent. We then closed the subdartos area with the subcutaneous closure of 4-0 chromic. We then did a similar curvilinear incision on the left side for testicular fixation. Delivered the testis into the field, which had a type III epididymal attachment and was indeed about 3 to 4 mL in size, which was larger than expected for the patient's age. We then closed the upper aspect of the subdartos pouch with the 4-0 chromic pursestring suture and placed testis back into the scrotum in the proper orientation and closed the dartos, skin, and subcutaneous closure with 4-0 chromic on left hemiscrotum. At the end of the procedure, the patient received IV Toradol and had Dermabond tissue adhesive placed on both incisions and left testis was well descended in the scrotum at the end of the procedure. The patient tolerated procedure well, and was in stable condition upon transfer to the recovery room.urology, diagnostic laparoscopy, caudal block, testis fixation, undescended testis, subcutaneous closure, testis, orchiectomy, laparoscopy, testicular, scrotum

INDICATION: , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE: ,surgery, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal

GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Genitalia: Bilaterally descended testes without tenderness or masses. No hernias palpable. Rectal examination revealed normal sphincter tone, no rectal mass. Prostate was *. Stool was Hemoccult negative.general medicine, male exam, cardiovascular, ent, ears, endocrine, extremities, genitalia, hemoccult, musculoskeletal, pulmonary, auditory acuity, blurred vision, heart rate, nocturia, pedal edema, percussion, polydipsia, rectal mass, regular rhythm, respiratory rate, review of systems, swollen lymph nodes, tinnitus, intact bilaterally, masses,

PREOPERATIVE DIAGNOSIS: ,Degenerative arthritis of the left knee.,POSTOPERATIVE DIAGNOSIS:, Degenerative arthritis of the left knee.,PROCEDURE PERFORMED: , Total left knee replacement on 08/19/03. The patient also underwent a bilateral right total knee replacement in the same sitting and that will be dictated by Dr. X.,TOURNIQUET TIME: , 76 minutes.,BLOOD LOSS: , 150 cc.,ANESTHESIA: ,General.,IMPLANT USED FOR PROCEDURE:, NexGen size F femur on the left with #8 size peg tibial tray, a #12 mm polyethylene insert and this a cruciate retaining component. The patella on the left was not resurfaced.,GROSS INTRAOPERATIVE FINDINGS: , Degenerative ware of three compartments of the trochlea, the medial, as well as the lateral femoral condyles as well was the plateau. The surface of the patella was with a minimal ware and minimal osteophytes and we decided not to resurface the patellar component.,HISTORY: ,This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason, he is elected to undergo the above-named procedure.,All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively.,PROCEDURE: , The patient was wheeled back to operating room #2 at ABCD General Hospital on 08/19/03 and was placed supine on the operating room table. At this time, a nonsterile tourniquet was placed on the left upper thigh, but not inflated. An Esmarch was then used to exsanguinate the extremity and the left extremity was then prepped and draped in the usual sterile fashion for this procedure. The tourniquet was then inflated to 325 mmHg. At this time, a standard midline incision was made towards the total knee. We did discuss preoperatively for a possible unicompartmental knee replacement for this patient, but he did have radiographic evidence of chondrocalcinosis of the lateral meniscus. We did start off with a small midline skin incision in case we were going to do a unicompartmental. Once we exposed the medial parapatellar mini-arthrotomy and visualized the lateral femoral condyle, we decided that this patient would not be an optimal candidate for unicompartmental knee replacement. It is for this reason that we extended the incision and underwent with the total knee replacement. Once the full medial parapatellar arthrotomy was performed with the subperiosteal dissection of the proximal tibia in order to evert the patella. Once the patella was everted, we then used a drill to cannulate the distal femoral canal in order to place the intramedullary guide. A Charnley awl was then used to remove all the intramedullary contents and they were removed from the knee. At this time, a femoral sizer was then placed with reference to the posterior condyles and we measured a size F. Once this was performed, three degrees of external rotation was then drilled into the condyle in alignment with the epicondyles of the femur. At this time, the intramedullary guide was then inserted and placed in three degrees of external rotation. Our anterior cutting guide was then placed and an anterior cut was performed with careful protection of the soft tissues. Next, this was removed and the distal femoral cutting guide was then placed in five degrees of valgus. This was pinned to the distal femur and with careful protection of the collateral ligaments, a distal femoral cut was performed. At this time, the intramedullary guide was removed and a final cutting block was placed. This was placed in the center on the distal femur with 1 mm to 2 mm laterally translated for better patellar tracking. At this time, the block was pinned and screwed in place with spring pins with careful protection of the soft tissues. An oscillating saw was then used to resect the posterior and anterior cutting blocks with anterior and posterior chamfer as well as the notch cut. Peg holes were then drilled.,The block was then removed and an osteotome was then used to remove all the bony cut pieces. At this time with a better exposure of the proximal tibia, we placed external tibial guide. This was placed with longitudinal axis of the tibia and carefully positioned in order to obtain an optimal cut for the proximal tibia. At this time with careful soft tissue retraction and protection, an oscillating saw was used to make a proximal tibial osteotomy. Prior to the osteotomy, the cut was checked with a depth gauge in order to assure appropriate bony resection. At this time, a _blunt Kocher and Bovie cautery were used to remove the proximal tibial cut, which had soft tissue attachments. Once this was removed, we then implanted our trial components of size F to the femur and a size 8 mm tibial tray with 12 mm plastic articulating surface. The knee was taken through range of motion and revealed excellent femorotibial articulation. The patella did tend to sublux somewhat laterally with extremes of flexion and it was for this reason, we performed a minimal small incision lateral retinacular release. Distal lateral patella was tracked more uniformly within the patellar groove of the prosthesis. At this time, an intraoperative x-ray was performed, which revealed excellent alignment with no varus angulation especially of the whole femur and tibial alignment and tibial cut. At this time, the prosthesis was removed. A McGill retractor was then reinserted and replaced peg tibial tray in order to peg the proximal tibia. Once the drill holes were performed, we then copiously irrigated the wound and then suctioned it dry to get ready and prepped for cementation of the drilled components. At this time, polymethyl methacrylate cement was then mixed. The cement was placed on the tibial surface as well as the underneath surface of the component. The component was then placed and impacted with excess cement removed. In a similar fashion, the femoral component was also placed. A 12 mm plastic tray was then placed and the leg held in full extension and compression in order to obtain adequate bony cement content. Once the cement was fully hardened, the knee was flexed and a small osteotome was used to remove any extruding cement from around the prosthesis of the bone. Once this was performed, copious irrigation was used to irrigate the wound and the wound was then suctioned dry. The knee was again taken through range of motion with a 12 mm plastic as well as #14. The #14 appeared to be a bit too tight especially in extremes of flexion. We decided to go with a #12 mm polyethylene tray. At this time, this was placed to the tibial articulation and then left in place. This was rechecked with careful attention to detail with checking no soft tissue interpositioned between the polyethylene tray and the metal tray of the tibia. The knee was again taken through range of motion and revealed excellent tracking of the patella with good femur and tibial contact. A drain was placed and cut to length.,At this time, the knee was irrigated and copiously suction dried. #1-0 Ethibond suture was then used to approximate the medial parapatellar arthrotomy in figure-of-eight fashion. A tight capsular closure was performed. This was reinforced with a #1-0 running Vicryl suture. At this time, the knee was again taken through range of motion to assure tight capsular closure. At this time, copious irrigation was used to irrigate the superficial wound. #2-0 Vicryl was used to approximate the wound with figure-of-eight inverted suture. The skin was then approximated with staples. The leg was then cleansed. Sterile dressing consisting of Adaptic, 4x4, ABDs, and Kerlix roll were then applied. At this time, the patient was extubated and transferred to recovery in stable condition. Prognosis is good for this patient.orthopedic, degenerative arthritis, nexgen, polyethylene, cruciate, total knee replacement, proximal tibia, knee replacement, femoral, cutting, tibial, knee, arthritis, femur, cementation,

PREOPERATIVE DIAGNOSIS: , Right inguinal hernia. ,POSTOPERATIVE DIAGNOSIS:, Right direct inguinal hernia. ,PROCEDURE:, Right direct inguinal hernia repair with PHS mesh system. ,ANESTHESIA:, General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was administered with endotracheal intubation. The Right groin and abdomen were prepped and draped in the standard sterile surgical fashion. An incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease. Dissection was taken down through the skin and subcutaneous tissue. Scarpa's fascia was divided, and the external ring was located. The external oblique was divided from the external ring up towards the anterior superior iliac spine. The cord structures were then encircled. Careful inspection of the cord structures did not reveal any indirect sac along the cord structures. I did, however, feel a direct sac with a direct defect. I opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac. Once I cleared out the preperitoneal space, I placed a PHS mesh system with a posterior mesh into the preperitoneal space, and I made sure that it laid flat along Cooper's ligament and covered the myopectineal orifice. I then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and I then tacked the medial portion of the mesh to the pubic tubercle with a 0 Ethibond suture. I tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament. I cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures. I then closed the external oblique with a running 3-0 Vicryl. I closed the Scarpa's with interrupted 3-0 Vicryl, and I closed the skin with a running Monocril. Sponge, instrument and needle counts were correct at the end of the case. The patient tolerated the procedure well and without any complications.urology, groin, phs mesh, inguinal hernia repair, direct inguinal hernia, preperitoneal space, external oblique, cord structures, inguinal hernia, inguinal, hernia, external, oblique, mesh,

CC:, Dysarthria,HX: ,This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of "tumor or reactive lymphocytosis." One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images.,MEDS: ,none.,PMH:, 1)G3P3, 2)last menses one year ago.,FHX:, Mother suffered stroke in her 70's. DM and Htn in family.,SHX:, Married, Secretary, No h/o tobacco/ETOH/illicit drug use.,ROS:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,EXAM:, BP139/74, HR 90, RR20, 36.8C,MS: Drowsy to somnolent, occasionally "giddy." Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart).,CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout. Normal muscle tone and bulk.,Sensory: No deficit to LT/PP/VIB/PROP.,Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.,Station: Romberg sign present.,Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.,Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),,No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.,Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.,Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.,She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.,She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.,Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility.nan

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.ent - otolaryngology, 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,

PREOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1. Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2. Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3. A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4. A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5. A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1. Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2. Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3. Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4. Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5. A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local. I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:, Less than 30 mL.,COMPLICATIONS: , None.,COUNTS: ,Sponge and needle counts were all correct.,PROCEDURE:, The patient was evaluated preop and noted to be in stable condition. Chart and informed consent were all reviewed preop. All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc. The areas of concern were marked with the marking pen. Local anesthetic was infiltrated. Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above. These were excised with the #15 blade. The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm. A suture was placed at the 12 o'clock superior margin. Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma. The healthy margin of healthy tissue around this lesion was removed. Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner. This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis. It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm. After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit. These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA. This was also an actinic keratosis. It is new in onset, just within the last week. Once a light frosting was obtained from the treatment site, bacitracin ointment was applied. Postop care instructions have been reviewed in detail. The patient is scheduled a recheck in one week for suture removal. We will make further recommendations at that time.nan

PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:, Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. The patient has now begun to have comorbidities related to the obesity. The patient has attended our bariatric seminar and met with our dietician and psychologist. The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient. Consent was obtained. The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was administered with endotracheal intubation. A Foley catheter was placed for bladder decompression. All pressure points were carefully padded, and sequential compression devices were placed on the legs. The abdomen was prepped and draped in standard, sterile, surgical fashion. Marcaine was injected into the umbilicus.surgery, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation

ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. This involved cough, post-tussive emesis, questionable fever, but only 99.7. Their usual doctor prescribed amoxicillin over the phone. The coughing persisted and worsened. She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells. They did witness some apnea. They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL: Well-developed, well-nourished baby in no apparent distress. HEENT: There was some nasal discharge. Remainder of the HEENT was normal. LUNG: Had few rhonchi. No retractions. No significant coughing or apnea during the admission physical. ABDOMEN: Benign. EXTREMITIES: Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS: ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP. An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate. Well at hospital, she had a rapid influenza swab done, which was negative. She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative. She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart. I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile. Required no oxygen in the hospital. Actually fed reasonably well. Did have one episode of coughing with slight emesis. Appeared basically quite well between episodes. Had no apnea witnessed and after overnight observation, the parents were anxious to go home. The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:, Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.general medicine, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,

PREOPERATIVE DIAGNOSIS: ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1. Urinary hesitancy and weak stream.,2. Urethral narrowing.,3. Mild posterior wall erythema.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Urethral dilation.,3. Bladder biopsy and fulguration.,ANESTHESIA: ,General.,SPECIMEN: ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS: ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:, Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French. A midureteral polyp was noted. Cystoscopy revealed multiple cellules and mild trabeculation of the bladder. Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa. No obvious raised bladder tumor was noted. No foreign bodies were noted. The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia. The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope. Cystoscopy was performed in its entirety with the above findings. The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area. The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined. No evidence of active bleeding noted. The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks. She is given prescription for Levaquin and Pyridium and given discharge instructions.surgery, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,

TECHNIQUE: , Sequential axial CT images were obtained through the facial bones without contrast. Additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures.,FINDINGS:, The osseous structures within the face are intact with no evidence of fracture or dislocation. The visualized paranasal sinuses and mastoid air cells are clear. The orbits and extra-ocular muscles are within normal limits. The soft tissues are unremarkable. ,IMPRESSION: , No acute abnormalities.radiology, sequential axial ct image, ct facial, osseous structuresNOTE

CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw. The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured. The patient states that the pain in her left lower teeth kept her up last night. The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care. The patient states that the pain continues to be very severe at 9/10. She states that this is like a throbbing heart beat in her left jaw. The patient denies fevers or chills. She denies purulent drainage from her gum line. The patient does believe that there may be an area of pus accumulating in her gum line however. The patient denies nausea or vomiting. She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1. Coronary artery disease.,2. Hypertension.,3. Hypothyroidism.,PAST SURGICAL HISTORY: ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage. Currently she does have a history of tobacco abuse.,MEDICATIONS:,1. Plavix.,2. Metoprolol.,3. Synthroid.,4. Potassium chloride.,ALLERGIES:,1. Penicillin.,2. Sulfa.,PHYSICAL EXAMINATION:,GENERAL: This is a Caucasian female who appears of stated age of 45 years. She is well-nourished, well-developed, in no acute distress. The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS: Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT: Head is normocephalic. Pupils are equal, round and reactive to light and accommodation. Sclerae are anicteric and noninjected. Nares are patent and free of mucoid discharge. Mucous membranes are moist and free of exudate or lesion. Bilateral tympanic membranes are visualized and free of infection or trauma. Dentition shows significant decay throughout the dentition. The patient has had extraction of teeth 17, 18, and 19. The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site. There is no pus draining from the socket of the tooth. No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE: ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth. The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT: ,Dental pain with likely dental abscess. ,PLAN: , The patient was given a prescription for Vicodin. She is also given prescription for Keflex, as she is penicillin allergic. She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity. The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so. The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,nan

PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:, MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1. Left frontal craniotomy for placement of deep brain stimulator electrode.,2. Right frontal craniotomy for placement of deep brain stimulator electrode.,3. Microelectrode recording of deep brain structures.,4. Stereotactic volumetric CT scan of head for target coordinate determination.,5. Intraoperative programming and assessment of device.,INDICATIONS: ,The patient is a 61-year-old woman with a history of dystonic tremor. The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation. The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives. She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:, The patient was brought to the holding area and to the operating room in stable condition. She was placed on the operating table in seated position. Her head was shaved. Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes. IV antibiotics were administered as was the sedation. She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken. The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen. Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint. Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again. Foley catheter was placed, and she was secured to the table using the Mayfield unit. At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes. Sterile drapes placed around the perimeter of the field. This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings. Bur holes were created on either side of the midline just behind the coronal suture. Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field. Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill. The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade. The cortical surface was then nicked with a #11 blade on both sides as well. The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame. Microelectrode drive was secured to the arc. Microelectrode recording was then performed. The signatures of the cells were recognized. Microelectrode unit was removed. Deep brain stimulating electrode holding unit was mounted. The DBS electrode was then loaded into target and intraoperative programming and testing was performed. Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side. This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system. The microelectrode unit was then remounted. Microelectrode recording was then undertaken. After multiple passes, the microelectrode unit was removed. Deep brain stimulator electrode holding unit was mounted at the desired trajectory. The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box. Using standard parameters, the patient experienced similar results on her right side. This electrode was secured using bur-hole ring and cap system. The arc was then removed. A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally. Copious amounts of Betadine irrigation were used. Hemostasis was controlled using the bipolar only. Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples. Sterile dressings were applied. The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition. All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.neurosurgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,

CHIEF COMPLAINT:, "My potassium is high",HISTORY OF PRESENT ILLNESS:, A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY:, Mone.,MEDICATIONS:, Occasional acetaminophen.,ALLERGIES:, NKDA.,SOCIAL HISTORY:, He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures.,FAMILY HISTORY:, There was a history of coronary artery disease and diabetes mellitus in the family.,PHYSICAL EXAM:,VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy.,CHEST X-RAY:, Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range.,CHEST CT SCAN:, Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications.,ABDOMINAL CT SCAN: ,Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen.,TESTICULAR ULTRASOUND: ,There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal.,HOSPITAL COURSE:, The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed.general medicine, potassium is high, chest x-ray, chest ct scan, abdominal ct scan, testicular ultrasound, lymph node, ct scan, blood pressure, abdominal, multiple, subcarinal, epididymis, potassium, lymphadenopathy,

PREOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,POSTOPERATIVE DIAGNOSIS:, Right superior parathyroid adenoma.,PROCEDURE: , Excision of right superior parathyroid adenoma.,ANESTHESIA:, Local with 1% Xylocaine and anesthesia standby with sedation.,CLINICAL HISTORY:, This 80-year-old woman has had some mild dementia. She was begun on Aricept but could not tolerate that because of strange thoughts and hallucinations. She was found to be hypercalcemic. Intact PTH was mildly elevated. A sestamibi parathyroid scan and an ultrasound showed evidence of a right superior parathyroid adenoma.,FINDINGS AND PROCEDURE:, The patient was placed on the operating table in the supine position. A time out was taken so that the anesthesia personnel, nursing personnel, surgical team, and patient could confirm the patient's identity, operative site and operative plan. The electronic medical record was reviewed as was the ultrasound. The patient was sedated. A small roll was placed behind the shoulders to moderately hyperextend the neck. The head was supported in a foam head cradle. The neck and chest were prepped with chlorhexidine and isolated with sterile drapes. After infiltration with 1% Xylocaine with epinephrine along the planned incision, a transverse incision was made in the skin crease a couple of centimeters above the clavicular heads and carried down through the skin, subcutaneous tissue, and platysma. The larger anterior neck veins were divided between 4-0 silk ligatures. Superior and inferior flaps were developed in the subplatysmal plane using electrocautery and blunt dissection. The sternohyoid muscles were separated in the midline, and the right sternohyoid muscle was retracted laterally. The right sternothyroid muscle was divided transversely with the cautery. The right middle thyroid vein was divided between 4-0 silk ligatures. The right thyroid lobe was rotated leftward. Posterior to the mid portion of the left thyroid lobe, a right superior parathyroid adenoma of moderate size was identified. This was freed up and its pedicle was ligated with small Hemoclips and divided and the gland was removed. It was sent for weight and frozen section. It weighed 960 mg and on frozen section was consistent with a parathyroid adenoma.,Prior to the procedure, a peripheral blood sample had been obtained and placed in a purple top tube labeled "pre-excision." It was our intention to monitor intraoperative intact parathyroid hormone 10 minutes after removal of this parathyroid adenoma. However, we could not obtain 3 cc of blood from either the left foot or the left arm after multiple attempts, and therefore, we decided that the chance of cure of hyperparathyroidism by removal of this parathyroid adenoma was high enough and the improvement in that chance of cure marginal enough that we would terminate the procedure without monitoring PTH. The neck was irrigated with saline and hemostasis found to be satisfactory. The sternohyoid muscles were reapproximated with interrupted 4-0 Vicryl. The platysma was closed with interrupted 4-0 Vicryl, and the skin was closed with subcuticular 5-0 Monocryl and Dermabond. The patient was awakened and taken to the recovery area in satisfactory condition having tolerated the procedure well.surgery, parathyroid adenoma, superior parathyroid adenoma, excision, sestamibi parathyroid scan, sestamibi parathyroid, parathyroid scan, sternohyoid muscles, superior parathyroid, parathyroid, sestamibi, platysma, adenoma, ultrasound, sternohyoid, thyroid, muscles

PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE: ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION: ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face. She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call. The patient was worked up initially. On initial exam, it was noted that the patient had a left V3 paresthesia. She had a gross malocclusion. On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture. Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table. Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion. Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion. A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush. The Peridex was evacuated with Yankauer suction. Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth. Same was done on the mandible. The patient was then manipulated up in the maximum intercuspation and noted to be reproducible. The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics. At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.surgery, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible,

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:, Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:, Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:, The patient was placed in the prone position after general endotracheal anesthesia was administered. The scalp was prepped and draped in the usual fashion. The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor. Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor. The bone flap was elevated. The ultrasound was then used. The ultrasound showed the tumors directly I believe are in the interhemispheric fissure. We noticed that the dura was quite tense despite that the patient had slight hyperventilation. We gave 4 ounce of mannitol, the brain became more pulsatile. We then used the stealth to perform a ventriculostomy. Once this was done, the brain began to pulsate nicely. We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus. After having done this we then used operating microscope and slight self-retaining retraction was used. We obtained access to the tumor. We biopsied this and submitted it. This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total. After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery. The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates. The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle. This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage. The next step was to close the wound after reapproximating the bone flap. The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures. The sterile dressings were applied to the scalp. The patient returned to the recovery room in satisfactory condition. Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy. The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.neurosurgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,

PROCEDURE: , Bilateral L5 dorsal ramus block and bilateral S1, S2, and S3 lateral branch block.,INDICATION: , Sacroiliac joint pain.,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 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.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the 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, pillow under the chest, and head rotated contralateral to the side being treated. 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. Fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the SAP and sacrum through the dorsal ramus of the L5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of S1, S2, and S3. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately 0.25 mL of nonionic contrast agent was injected showing no concurrent vascular dye pattern. Finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area. All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: , This was then repeated on the left side.,COMPLICATIONS: , None.,DISCUSSION: ,Postprocedure 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 resume 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 at the PM&R Spine Clinic in approximately 1 week.orthopedic, sacroiliac, lateral branch block, ramus block, branch block, sacroiliac joint, dorsal ramus, fluoroscopic, branch, dorsal, ramus, bilateral, needle, block,

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.urology, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants. The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed. No leakage of enteral contents was noted. All trocars were removed under direct visualization. The umbilical fascia was closed with interrupted 0 Vicryl sutures. The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's. The patient was extubated and taken to the recovery area in stable condition. The patient tolerated the procedure well.surgery, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical

PREOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Pelvic pain.,3. Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS: ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:, This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus. On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm. She had received two dosage of Lupron to help shrink the fibroid. Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated. On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm. The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament. There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:, After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic. The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion. A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife. The fascia was incised in midline and the incision extended laterally using Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors. Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles. The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors. This incision was extended superiorly and inferiorly with good visualization of the bladder. The uterus was then brought up out of the incision. The bowel adhesions were carefully taken down using Metzenbaum scissors. Good hemostasis was noted at this point. The self-retaining retractor was then placed. The bladder blade was placed. The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension. The uterus was then grasped with a Lahey clamp and brought up out of the incision. The left round ligament was identified and grasped with Allis clamp and tented up. A hemostat was passed in the avascular area beneath the round ligament. A suture #0 Vicryl was used to suture ligate the round ligament. Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament. An avascular area of the broad ligament was then identified and entered bluntly. The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament. Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture. The ligament was then transected and suture ligated with #0 Vicryl. Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp. An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected. An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture. This was then transected and suture ligated again with #0 Vicryl. The left uterine peritoneum was then identified and grasped with Allis clamps. The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors. This incision was extended across the anterior portion of the uterus and the bladder flap was taken down. It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec. The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix. The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's. Each were then transected and suture ligated with #0 Vicryl. A curved Ochsner was then placed on either side of the cervix. The tissue was transected using a long knife and suture ligated with #0 Vicryl. Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie. The cervix was then grasped with a Lahey clamp. The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix. A double-pointed scissors were used to enter the vaginal vault below the level of the cervix. A straight Ochsner was placed on the vaginal vault. The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue. The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated. There was a small area of bleeding noted on the underside of the bladder. The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point. The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down. A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament. The round ligament was too short. It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff. The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion. The bladder flap was reapproximated to the vaginal cuff using one interrupted suture. The pelvis was again irrigated at this point with excellent hemostasis noted. Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder. There was no spillage of blue fluid into the abdomen. The fluid again was allowed to drain. All sponges were then removed and the bowel was allowed to return to its anatomical position. The peritoneum was then reapproximated with #0 Vicryl in a running fashion. The fascia was reapproximated also with #0 Vicryl in a running fashion. The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault. There was no appreciable bleeding. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in satisfactory condition. She will be followed immediately postoperatively within the hospital.obstetrics / gynecology, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum,

HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1. Vicodin 500 mg two times a day.,2. Risperdal.,3. Zoloft.,4. Stool softeners.,5. Prenatal pills.,DIAGNOSTIC IMAGERY: ,The patient states she has not had an MRI performed on her lumbar spine. The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time. Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE: ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE: 26 years old. HEIGHT: 5 feet 2 inches. WEIGHT: The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION: ,The patient complained of bilateral SI joint point tenderness. The patient also complained of left greater trochanter hip point tenderness. The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH: ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5. With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance. It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL: ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes. However, they subside when she stands. The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes. Upon standing, the patient stated that the numbness and tingling subsides almost immediately. The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities. The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT: ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT: ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain. The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued. At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1. The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2. The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3. The patient will report 25% improvement in her functional and ADL activities.,4. Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1. The patient will be independent with home exercise program.,2. Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3. The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4. The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5. The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1. Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.nan

TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis. The vertebral body heights and disc spaces are maintained. The central canal is patent. The pedicles and posterior elements are intact. The paravertebral soft tissues are within normal limits. The atlanto-dens interval and the dens are intact. The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE

PROCEDURE:, Left Cardiac Catheterization, Left Ventriculography, Coronary Angiography and Stent Placement.,INDICATIONS: , Atherosclerotic coronary artery disease.,PATIENT HISTORY: , This is a 55-year-old male. He presented with 3 hours of unstable angina.,PAST CARDIAC HISTORY: , History of previous arteriosclerotic cardiovascular disease. Previous ST elevation MI.,REVIEW OF SYSTEMS., The creatinine value is 1.3 mg/dL mg/dL.,PROCEDURE MEDICATIONS:,1. Visipaque 361 mL total dose.,2. Clopidogrel bisulphate (Plavix) 225 mg PO,3. Promethazine (Phenergan) 12.5 mg total dose.,4. Abciximab (Reopro) 10 mg IV bolus,5. Abciximab (Reopro) 0.125 mcg/kg/minute, 4.5 mL/250 mL D5W x 17 mL,6. Nitroglycerin 300 mcg IC total dose.,DESCRIPTION OF PROCEDURE:,APPROACH: , Left heart catheterization via right femoral artery approach.,ACCESS METHOD: , Percutaneous needle puncture.,DEVICES USED:,1. Balloon catheter utilized: Manufacturer: Boston Sci Quantum Maverick RX 2.75mm x 20mm.,2. Cordis Vista Brite Tip 6Fr JR 4.0,3. ACS/Guidant Sport .014" (190cm) Wire,4. Stent utilized: Boston Sci Taxus RX Stent 3.0mm x 32mm.,FINDINGS/INTERVENTIONS:,LEFT VENTRICULOGRAPHY:, The overall left ventricular systolic function is mildly reduced. Left ventricular ejection fraction is 40% by left ventriculogram. Mild hypokinesis of the anterior wall of the left ventricle. There was no transaortic gradient. Mitral valve regurgitation is not seen.,LEFT MAIN CORONARY ARTERY: , There were no obstructing lesions in the left main coronary artery. Blood flow appeared normal.,LEFT ANTERIOR DESCENDING ARTERY: , There was a 95%, discrete stenosis in the mid left anterior descending artery. A drug eluting, Boston Sci Taxus RX Stent 3.0mm x 32mm stent was placed in the mid left anterior descending artery and post-dilated to 3.5 mm. Post-procedure stenosis was 0%. There was no dissection and no perforation.,LEFT CIRCUMFLEX ARTERY: , There was a 50%, diffuse stenosis in the left circumflex artery.,RIGHT CORONARY ARTERY:, The right coronary artery is dominant to the posterior circulation. There were no obstructing lesions in the right coronary artery. Blood flow appeared normal.,COMPLICATIONS:,There were no complications during the procedure., ,IMPRESSION:,1. Severe two-vessel coronary artery disease.,2. Severe left anterior descending coronary artery disease. There was a 95% mid left anterior descending artery stenosis. The lesion was successfully stented.,3. Moderate left circumflex artery disease. There was a 50% left circumflex artery stenosis. Intervention not warranted.,4. The overall left ventricular systolic function is mildly reduced with ejection fraction of 40%. Mild hypokinesis of the anterior wall of the left ventricle.,RECOMMENDATION:,1. Clopidogrel (Plavix) 75 mg PO daily for 1 year.nan

PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:, Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass. On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy. The patient had good anterior support at the bladder. Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed. The patient understood all the risks and benefits and wanted to proceed with the procedure. Risk of retention and incontinence were discussed. Consent was obtained through the family members.,DETAILS OF THE OR:, The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient had a Foley catheter placed. The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support. A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part. Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring. Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive. Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis. Oral consent was obtained from the family and her surgery was preceded. The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors. Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus. The vaginal mucosa was pretty much completely closed off all the way up to the introitus. Indigo carmine was given. Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings. There was no injury to the bladder or kinking of the ureteral openings. The bladder was normal. Rectal exam was normal at the end of the colpocleisis repair. There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,

REASON FOR VISIT:, Preop evaluation regarding gastric bypass surgery.,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet.,PHYSICAL EXAMINATION: , The patient is alert and oriented x3. Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. Abdomen: Soft, nontender, and nondistended.,ASSESSMENT AND PLAN:, The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. Questions regarding hospital course and recovery were addressed. We will continue on the Medifast diet until the time of surgery and cleared for surgery.soap / chart / progress notes, medifast, medifast diet, preop evaluation, gastric bypass surgery, bypass surgery, gastric bypass,

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY: ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock. Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: This is an overweight African-American female not in any distress.,VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range.,HEENT: Normal to inspection.,NECK: No bruits or adenopathy.,LUNGS: Clear to auscultation.,CV: Regular rate and rhythm.,ABDOMEN: Protuberant, soft, and nontender.,EXTREMITIES: No clubbing, cyanosis or edema.,RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details.dermatology, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

PREOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,PROCEDURE PERFORMED:,1. Adenoidectomy and tonsillectomy.,2. Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:, Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION: ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A curved hemostat was used to grasp the lingual frenulum. The stat was removed and Metzenbaum scissors were used to free the lingual frenulum. Cautery was used to allow hemostasis. The patient was then turned. McIvor mouth gag was inserted. Tonsils and adenoids were exposed. The patient's right tonsil was first grasped with a curved hemostat. Needle tip cautery was used to free the superior pole of tonsil. The tonsil was then grasped in medial superior aspect with a straight hemostat. The tonsil fascia planes were identified with Bovie dissection along the plane. The tonsil was freed from anterior pillar and posterior pillar. Amputation occurred along the same plane as the patient's tongue. Suction cautery was then used to allow for hemostasis. The patient's adenoids were then viewed with an adenoid mirror. An adenoid curet was used to remove the patient's adenoid tissue. Specimen sent. Suction cautery was used to allow for hemostasis. Superior pole of left tonsil was then grasped with a curved hemostat. Superior pole was freed using needle tip Bovie dissection. Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars. The tonsil was then amputated at the same plane as tongue base. Hemostasis was achieved with using suction cautery. Mouth gag was removed. Dual position and occlusion were tested. The patient was extubated and tolerated the procedure well and sent back to PACU.ent - otolaryngology, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.,REVIEW OF SYSTEMS:, CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:, None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana. The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated.,DIAGNOSES:,1. ACUTE LEFT JAW PAIN.,2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3. ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.neurology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,

FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.orthopedic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal

PROCEDURE:, Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained. Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL: ,The patient was placed in the left lateral decubitus position. Medications were given. After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,

BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings. Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized. This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures. The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin. This created a significant crisp, supratarsal fold. The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus. The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking. Then the skin muscle flap was elevated with sharp dissection. The fat was located and using a scissor the three eyelid compartments were opened. Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized. Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed. The suture line was sutured with interrupted 6-0 silk sutures. Once this was done the procedure was finished.,The patient left the OR in satisfactory condition. The patient was given 50 mg of Demerol IM with 25 mg of Phenergan.surgery, blepharoplasty, green forceps, wydase, applicator, canthus, lash line, lazy s, lazy s fashion, muscle flap, periorbital muscle, prepped and draped, supratarsal fold, upper lid, upward gaze, upper lid skin, eyelidsNOTE,: 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 CONSULTATION: ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. He noticed a small dark spot. He did not remember having had any injuries to that area specifically no puncture wounds. He had not been doing any outdoor works or activities. No history of working outdoors, has not been to the beach or to the lake, has not been out of town. His swelling progressed so he went to see Dr. X 4 days ago. The area was debrided in the office and he was placed on Keflex. It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies. His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening. Ancef and Cipro were prescribed today. He denies any fever, chills, red streaks, lymphadenitis. He had a tetanus shot in 2002 most recently. He had childhood asthma. He uses alcohol socially. He works full time. He is an electrician.,ALLERGIES:, ACCUTANE.,PHYSICAL EXAMINATION,GENERAL: Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS: His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT: Mouth unremarkable.,NECK: Supple.,LUNGS: Clear.,HEART: Regular rate rhythm. No murmur or gallop.,ABDOMEN: Soft and nontender.,EXTREMITIES: Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema. There is bloodied blister around it. The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema. There is some mild intertrigo between the fourth and fifth left toes. Palpable pedal pulses. Leg unremarkable. No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110. Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal. PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION: ,Abscess of the left foot, etiology unclear at this time. Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour. Cultures, Gram stain, fungal cultures, and smear to be obtained. I have changed his antibiotic to vancomycin plus Maxipime. He is currently on tetanus immunizations so no need for booster at this time.,podiatry, accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,

PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,INDICATION: ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:, After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE: ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.,RCA:, RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.,IMPRESSION,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.nan

PREOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,POSTOPERATIVE DIAGNOSIS: , Autism with bilateral knee flexion contractures.,PROCEDURE: , Left distal medial hamstring release.,ANESTHESIA: , General anesthesia. Local anesthetic 10 mL of 0.25% Marcaine local.,TOURNIQUET TIME: , 15 minutes.,ESTIMATED BLOOD LOSS: ,Minimal.,COMPLICATIONS: ,There were no intraoperative complications.,DRAIN: ,None.,SPECIMENS: ,None.,HISTORY AND PHYSICAL: ,The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play. The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed. Risks and benefits of the surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures. All questions were answered and mother and son agreed to above plan.,PROCEDURE NOTE: ,The patient was taken to operating room and placed supine on operating table. General anesthesia was administered. The patient received Ancef preoperatively. Nonsterile tourniquet was placed on the upper aspect of the patient's left thigh. The extremity was then prepped and draped in standard surgical fashion. The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg. Esmarch was then removed. A small 3 cm incision was made over the distal medial hamstring. Hamstring tendons were isolated and released in order of semitendinosus, semimembranosus, and sartorius. The wound was then irrigated with normal saline and closed used 2-0 Vicryl and then 4-0 Monocryl. The wound was cleaned and dried and dressed with Steri-Strips. The area was infiltrated with total 10 mL of 0.25% Marcaine. The wound was then covered with Xeroform, 4 x 4s, and Bias. Tourniquet was released at 15 minutes. The patient was then placed in knee immobilizer. The patient tolerated the procedure well and subsequently taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The patient may weight bear as tolerated in his brace. He will start physical therapy in another week or two. The patient restricted from any PE for at least 6 week. He may return to school on 01/04/2008. He was given Vicodin for pain.surgery, medial hamstring release, distal medial hamstring release, bilateral knee flexion contractures, bilateral knee, hamstring release, knee flexion, tourniquet, flexion, contractures, hamstring,

HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.,PAST MEDICAL HISTORY:, The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:, She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL: The patient is an elderly frail white female in no distress. LUNGS: Clear. HEART: Sounds are regular. ABDOMEN: She has a protuberant abdomen. She has tenderness to palpation in the lumbosacral area. Sciatic notch tenderness is not present. Straight leg raise testing evokes back pain. NEUROLOGICAL: She is awake, alert, and oriented. Speech is intact. Comprehension is normal. Strength is intact in the upper extremities. She has giveaway strength in the lower extremities. Reflexes are diminished at the knees and ankles. Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture. A CT scan has shown some healing of this fracture. She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain. She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments. At this point, I believe the patient is a good candidate for L5 kyphoplasty. I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery. Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. The patient understands the issues involved. She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.consult - history and phy., leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,

S -, A 60-year-old female presents today for care of painful calluses and benign lesions.,O -, On examination, the patient has bilateral bunions at the first metatarsophalangeal joint. She states that they do not hurt. No pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally. The patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot. She has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter. This is a central plug. She also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter. This is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,A - ,1. Bilateral bunions.,podiatry, painful calluses, hibiclens, scrubbed, ointment and absorbent, heloma durum, plantar aspect, minimal hemostasis, neosporin ointment, absorbent dressing, benign lesions, metatarsophalangeal, bunions, calluses, plantar,

PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease. She has not been able to feed well and in fact has to now be NG tube fed. Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE: ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner. Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. The muscle was divided and the peritoneal cavity entered. The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field. The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall. A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia. The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl. The balloon was inflated to the full 5 mL. A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,gastroenterology, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy

REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above.nan

PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication. She had severe dyspareunia and chronic suprapelvic pain. The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process. Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain. She desired surgical treatment. She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs. The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa. Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon. Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind. Ureter visualized and palpated on right and appears normal. Indigo carmine given IV with no leaks intraperitoneally noted. Sigmoid colon dissected free from back of uterus and from cul-de-sac. Bowel free of lacerations or denudation. Upon inspection, right tube with hydrosalpinx, appendix absent. Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia. She was placed in a supine position with a transurethral Foley in place and compression stockings in place. The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum. The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs. Next, exploration of the abdominal and pelvic organs revealed the above noted findings. The uterus was enlarged and probably contained adenomyosis. There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within. The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus. A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges. Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel. Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb. The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder. The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted. Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed. The right round ligament was suture-ligated with 0 Polysorb. It was transected and divided with electrocautery. The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular. The left infundibulopelvic ligament was identified. It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted. Next, the uterine arteries were skeletonized on the right. They were transected and suture-ligated with 0 Polysorb. The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb. The cardinal ligaments were taken near their insertion into the cervical and uterine tissue. Pedicles were sharply developed and suture-ligated with 0 Polysorb. Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina. Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors. The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support. The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon. It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind. The right ureter was seen and palpated. It did not appear to be dilated and had good peristalsis noted. Next, the retractors were removed. The laparotomy sponges were removed from the abdomen. The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline. The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion. The skin was closed with 4-0 Polysorb in a subcuticular fashion. A thin layer of Dermabond was placed.,The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x 2. Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:, None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,nan

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

CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus.orthopedic, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,nan

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.hematology - oncology, colon cancer screening, loose stools, colorectal, colonoscopy,

PROCEDURES:,1. Placement of SynchroMed infusion pump.,2. Tunneling of SynchroMed infusion pump catheter,3. Anchoring of the intrathecal catheter and connecting of the right lower quadrant SynchroMed pump catheter to the intrathecal catheter.,DESCRIPTION OF PROCEDURE: , Under general endotracheal anesthesia, the patient was placed in a lateral decubitus position. The patient was prepped and draped in a sterile manner. The intrathecal catheter was placed via a percutaneous approach by the pain management specialist at which point an incision was made adjacent to the needle containing the intrathecal catheter. This incision was carried down through the skin and subcutaneous tissue to the paraspinous muscle fascia which was cleared around the entry point of the intrathecal catheter needle. A pursestring suture of 3-0 Prolene was placed around the needle in the paraspinous muscle. The needle was withdrawn. The pursestring suture was tied to snug the tissues around the catheter and prevent cerebrospinal fluid leak. The catheter demonstrated free flow of cerebrospinal fluid,throughout the RV procedure. The catheter was anchored to the paraspinous muscle with an anchoring device using interrupted sutures of 3-0 Prolene. Antibiotic irrigation and antibiotic soak sponge were placed into the wound, and the catheter was clamped to prevent persistent leakage of cerebrospinal fluid while the SynchroMed-pump pocket was created. Then, I turned my attention to the anterior abdominal wall where an oblique incision was made and carried down through the skin and subcutaneous tissue to the external oblique fascia, which was freed from attachments to the overlying subcutaneous tissue utilizing blunt and sharp dissection with electrocautery. A pocket was created that would encompass the SynchroMed fusion pump. A tunneling device was then passed through the subcutaneous tissue from the back incision to the abdominal incision, and a SynchroMed pump catheter was placed to the tunneling device. The tunneling device was then removed leaving the SynchroMed pump catheter extending from the anterior abdominal wall incision to the posterior back incision. The intrathecal catheter was trimmed. A clear plastic boot was placed over the intrathecal catheter, and the connecting device was advanced from the SynchroMed pump catheter into the intrathecal catheter connecting the 2 catheters together. The clear plastic boot was then placed over the connection, and it was anchored in place with 0-silk ties. Good CSF was then demonstrated flowing through the SynchroMed pump catheter. The SynchroMed pump catheter was connected to the SynchroMed pump and anchored in place with a 0-silk tie. Excess catheter was coiled and placed behind the pump. The pump was placed into the subcutaneous pocket created for it on the anterior abdominal wall. The pump was anchored to the anterior abdominal wall fascia with interrupted sutures of 2-0 Prolene; 4 of the sutures were placed. The subcutaneous tissues were irrigated with normal saline. The subcutaneous tissue of both wounds was closed with running suture of 3-0 Vicryl. The skin of both wounds was closed with staples. Antibiotic ointment and a sterile dressing were applied. The patient was awake and taken to the recovery room. The patient tolerated the procedure well and was stable at the completion of the procedure. All sponge and lap, needle and instrument counts were correct at the completion of the procedure.surgery, intrathecal, catheter, paraspinous, cerebrospinal, synchromed infusion pump, synchromed pump catheter, synchromed pump, paraspinous muscle, cerebrospinal fluid, tunneling device, infusion pump, subcutaneous tissue, infusion, synchromed, pump, incision,

HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids only. He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips. Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow. Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid. Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow. The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule. The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids. The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food. The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling. Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation. The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid. No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1. The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2. The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3. The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4. The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient. I look forward to working with him in the outpatient setting to improve his swallowing function and safety. Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.consult - history and phy., oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing,

PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:, Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,surgery, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,

HISTORY OF PRESENT ILLNESS:, The patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. He has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. The main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. During his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his INR has been followed up by the Homeless Clinic. For his congestive cardiac failure, he was restarted on Digoxin and lisinopril. For his hyperthyroidism, we restarted him on PTU and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. He was restarted on PTU and discharged from the hospital on this medication. While in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. It was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. Since his discharge, his hepatitis panel has come back normal for hepatitis A, B, and C. Since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,MEDICATIONS:, Digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, PTU (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on INR.,PHYSICAL EXAMINATION:,VITAL SIGNS: He was afebrile today. Blood pressure 114/98. Pulse 92 but irregular. Respiratory rate 25.,HEENT: Obvious exophthalmus, but no obvious lid lag today.,NECK: There was no thyroid mass palpable.,CHEST: Clear except for occasional bibasilar crackles.,CARDIOVASCULAR: Heart sounds were dual, but irregular, with no additional sounds.,ABDOMEN: Soft, nontender, nondistended.,EXTREMITIES: Mild +1 peripheral edema in both legs.,PLAN:, The patient has also been attending the Homeless Clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. It is our recommendation that a TSH and T4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with Dr. Huffman for further treatment of his hyperthyroidism. Regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. His rate in clinic today was 92. He could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. Regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. He states he has been taking his wife's Lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. We should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. A Digoxin level has not been repeated since discharge, and we feel that this should be followed up. We have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. Regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.office notes, congestive cardiac failure, ejection fraction, atrial fibrillation, congestive cardiac, cardiac failure, office, lisinopril, metoprolol, hepatitis, fibrillation, hyperthyroidism, atrial, cardiac, congestive,

CC: ,Vertigo.,HX: ,This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,OUTSIDE RECORDS:, 12/16/92 Carotid Doppler (RICA 30-40%, LICA 10-20%). 12/4/92, brain MRI revealed a right cerebellar hypodensity consistent with infarct.,MEDS:, Zantac 150mg bid, Proventil MDI bid, Azmacort MDI bid, Doxycycline 100mg bid, Premarin 0.625mg qd, Provera 2.5mg qd. ASA 325mg qd.,PMH:, 1)MDD off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p Caldwell-Luc 1978, and nasal polypectomy. 6) GERD. 7)h/o elevated TSH. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: BE 11/24/92 and UGI 11/25/92 negative.,FHX: ,Father died of a thoracic aortic aneurysm, age 71. Mother died of stroke, age 81.,SHX:, Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.,EXAM,: BP (RUE)132/72 LUE (136/76). HR67 RR16 Afebrile. 59.2kg.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Thought lucid.,CN: unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits appreciated.,Coord: unremarkable.,Station: no pronator drift, truncal ataxia, or Romberg sign.,Gait: not done.,Reflexes: 2/2 throughout BUE and at patellae. 1/1 at Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese.,COURSE: ,CBC, GS, PT/PTT, UA were unremarkable. The patient was admitted with a working diagnosis of posterior circulation TIA and history of cerebellar stroke. She was placed on Ticlid 250mg bid. HCT,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. MRI and MRA, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. An abnormal vascular blush was seen on the MRA. This area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 Cerebral Angiogram: The right cerebellar hemisphere lesion seen on MRI as a possible cavernous angioma was not seen on angiography. Upon review of the MRI and HCT the lesion was felt to probably represent an old infarction with hemosiderin deposition. The "vascular blush" seen on MRA was no visualized on angiography. The patient was discharged home on 1/25/93.consult - history and phy., avm, episode of lightheadedness, vascular malformation, cavernous angioma, vascular blush, cerebellar hemisphere, malformation, cavernous, angioma, angiography, lightheadedness, hemisphere, vertigo, cerebellar,

REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08. The patient underwent laparoscopic appendicectomy by Dr. X. The patient had postoperative paralytic ileus, which has resolved. The patient had developed left-sided chest pain yesterday. In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No recent fever.,ENT: Unremarkable.,RESPIRATORY: He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR: No known heart problems.,GASTROINTESTINAL: The patient denies nausea or vomiting. He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: Negative for diabetes or thyroid problems.,NEUROLOGIC: No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY: ,The patient is a nonsmoker. He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL: An 87-year-old gentleman, not toxic looking.,HEAD AND NECK: Oral mucosa is moist.,CHEST: Clear to auscultation. No wheezing. No crepitations. There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOMEN: Slightly distended. Bowel sounds are positive.,EXTREMITIES: He has 2+ to 3+ pedal swelling.,NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000. Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1. Ruptured appendicitis. The patient is 6 days post surgery. He is tolerating oral fluids and moving bowels.,2. Left-sided chest pain, need to rule out PE by distance of pretty low probability. The patient, however, has low-oxygen saturation. We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3. Fluid retention, manage as per surgeon.,4. Paralytic ileus, resolving.,5. Leukocytosis, we will monitor.nan

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.surgery, thoracic right-sided discectomy, herniated nucleus pulposus, discectomy, thoracic, herniated,

PREOPERATIVE DIAGNOSIS: ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1. Bronchoscopy with aspiration.,2. Left upper lobectomy.,PROCEDURE DETAILS: ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina. The carina was in the midline and sharp. Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions. Aspiration was carried out for backlog ________ examination. We then moved to left side, left upper lobe. There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction. No anatomic lesions were demonstrated. The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter. After proper position, utilizing Betadine solution, they were draped. A posterolateral left thoracotomy incision was performed. Hemostasis was secured with electrocoagulation. The chest wall muscle was then divided over the sixth rib. The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully. At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation. We examined the superior mediastinum. No lymph nodes were demonstrated as well as in the anterior mediastinum. Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe. Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe. Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue. From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short. Tumor mass was close to the artery at this time. We then directed ourselves once again to the lingual artery which was doubly ligated and cut free. The posterior artery of the superior branch was doubly ligated and cut free also. At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished. We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein. Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal. Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time. A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished. The anterior artery was seen in the clamp also and was separated and ligated and separated. At this time, the entire tumor in the left upper lobe was then removed. ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place. The clamp was then removed. No bleeding was seen at this time. Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology. We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position. At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture. The chest cavity was then closed. After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength. A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin. The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time. The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.surgery, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,

CHIEF COMPLAINT:, Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device. She struck herself in the head with the flag. There was no loss of consciousness. She did feel dizzy. She complained of a headache. She was able to walk. She continued to participate in her flag practice. She got dizzier. She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:, DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home. There is no smoking at home. There is second-hand smoke exposure.,FAMILY HISTORY: ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:, She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS: ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL: She is supine awake, alert, cooperative, and active child.,HEENT: Head atraumatic, normocephalic. Pupils equal, round, reactive to light. Extraocular motions intact and conjugate. Clear TMs, nose and oropharynx. Moist oral mucosa without noted lesions.,NECK: Supple, full painless nontender range motion.,CHEST: Clear to auscultation, equal, stable to palpation.,HEART: Regular without rubs or murmurs.,ABDOMEN: No abdominal bruits are heard.,EXTREMITIES: Equal femoral pulses are appreciated. Equal radial and dorsalis pedis pulses are appreciated. He moves all extremities without difficulty. Nontender. No deformity. No swelling.,SKIN: There was no significant bruising, lesions or rash about her abdomen. No significant bruising, lesions or rash.,NEUROLOGIC: Symmetric face and extremity motion. Ambulates without difficulty. She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:, The differential entertained includes head injury, anxiety, and hypertensive emergency. She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s. Her laboratory data shows a mildly elevated creatinine of 1.3. Urine is within normal. Urinalysis showing no signs of infection. Head CT read by staff has no significant intracranial pathology. No mass shift, bleed or fracture per Dr. X. A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90. No significant ST-T wave changes. No significant change from previous 09/2007 EKG. Her headache has resolved. She is feeling better. I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home. Follow up with her regular doctor. Blood pressures have normalized for her. She should return to emergency department on concern. They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.nan

PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table. General inhalational anesthesia was administered. The patient was draped in usual fashion. The prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 mL of local anesthetic using 1% Xylocaine with epinephrine 1:100,000. The incision was performed with a #15 blade. An 18-gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity. This was submitted for culture and sensitivity, anaerobic cultures and Gram stain. The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated. The cavity was irrigated with peroxide and saline. A 0.25-inch Penrose drain was placed and secured with a single #3-0 nylon suture. A 4 x 4 dressing was applied. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.surgery, i&d, incision and drainage, neck abscess, drainage, cavity, incision,

HISTORY OF PRESENT ILLNESS: This is a 91-year-old female who was brought in by family. Apparently, she was complaining that she felt she might have been poisoned at her care facility. The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. The patient apparently had a little bit of dry heaves, but no actual vomiting. She had just finished eating dinner. No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries. She has a pacemaker. She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS: Very difficult to get from the patient herself. She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. She initially stated that everything was wrong, but could not specify any specific complaints. Denies chest pain, back pain, or abdominal pain. Denies any extremity symptoms or complaints.,SOCIAL HISTORY: The patient is a nonsmoker. She is accompanied here with daughter who brought her over here. They were visiting the patient when this episode occurred.,MEDICATIONS: Please see list.,ALLERGIES: NONE.,PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. GENERAL: The patient is an elderly frail looking little lady lying on the gurney. She is awake, alert, and not really wanted to answer most of the questions I asked her. She does have a tremor with her mouth, which the daughter states has been there for "many years". HEENT: Eye exam is unremarkable. Oral mucosa is still moist and well hydrated. Posterior pharynx is clear. NECK: Supple. LUNGS: Actually clear with good breath sounds. There are no wheezes, no rales, or rhonchi. Good air movement. CARDIAC: Without murmur. ABDOMEN: Soft. I do not elicit any tenderness. There is no abdominal distention. Bowel sounds are present in all quadrants. SKIN: Skin is without rash or petechiae. There is no cyanosis. EXTREMITIES: No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE: I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly. After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better. Family states she seems more calm. They do not want to pursue any further workup at this time.,IMPRESSION: ACUTE EPISODE OF AGITATION.,PLAN: At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. The patient herself has good vital signs. She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient. Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC. She is discharged in stable condition.emergency room reports, acute episode of agitation, agitation,

REASON FOR REFERRAL: , Ms. A is a 60-year-old African-American female with 12 years of education who was referred for neuropsychological evaluation by Dr. X after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in July. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION:, Historical information was obtained from a review of available medical records and clinical interview with Ms. A. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, Ms. A presented to the ABC Hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop. Neurological evaluation with Dr. X confirmed left hemiparesis. Brain CT showed no evidence of intracranial hemorrhage or mass effect and that she received TPA and had moderate improvement in left-sided weakness. These symptoms were thought to be due to a right middle cerebral artery stroke. She was transferred to the ICU for monitoring. Ultrasound of the carotids showed 20% to 30% stenosis of the right ICA and 0% to 19% stenosis of the left ICA. On 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right MCA/CVA. At discharge on 08/06/2009, she was mainly on supervision for all ADLs and walking with a rolling walker, but tolerating increased ambulation with a cane. She was discharged home with recommendations for outpatient physical therapy. She returned to the Sinai ER on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt "just like the stroke." Brain CT on 08/2009/2009 was read as showing "mild chronic microvascular ischemic change of deep white matter," but no acute or significant interval change compared to her previous scan. Neurological examination with Dr. Y was within normal limits, but she was admitted for a more extensive workup. Due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,Followup CT on 08/10/2009 showed no significant interval change. MRI could not be completed due to the patient's weight. She was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that Ms. A referred to this as a second stroke.,Ms. A presented for a followup outpatient neurological evaluation with Dr. X on 09/22/2009, at which time a brief neuropsychological screening was also conducted. She demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty. During the current interview, Ms. A reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications. She also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning. When asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness. She reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the Social Security Agency that she works at. Note also that she had some difficulty explaining exactly what her job involved. She also reported having problems falling asleep at work and that she is working full-time although on light duty.,OTHER MEDICAL HISTORY: ,As mentioned, Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it "every other night." When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times "snoring" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,CURRENT MEDICATIONS: , Aspirin 81 mg daily, Colace 100 mg b.i.d., Lipitor 80 mg daily, and albuterol MDI p.r.n.,SUBSTANCE USE:, Ms. A denied drinking alcohol or using illicit drugs. She used to smoke a pack of cigarettes per day, but quit five to six years ago.,FAMILY MEDICAL HISTORY: , Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,SOCIAL HISTORY: , Ms. A completed high school degree. She reported that she primarily obtained B's and C's in school. She received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,She currently works for the Social Security Administration in data processing. As mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition. She is now living on her own. She has never driven. She reported that she continues to perform ADLs independently such as cooking and cleaning. She lost her husband in 2005 and has three adult daughters. She previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation. She also reported number of other family members who had recently passed away. She has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the Bahamas at the end of October.,PSYCHIATRIC HISTORY: , Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes.",TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Testnan

DELIVERY NOTE:, This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation at 1900 At this time, a bulging bag was noted, which ruptured and thick meconium was present. At 1937 hours, she delivered a viable male infant, left occiput, anterior. Mouth and nares suctioned well with a DeLee on the perineum. No nuchal cord present. Shoulders and body followed easily. Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance. Apgars 9 and 9. Pitocin 15 units infused via pump protocol. Placenta followed complete and intact with fundal massage and general traction on the cord. Three vessels are noted. She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area. Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL. The remainder of the lacerations was not at all bleeding and no other lacerations present. Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly. EBL was about 500 mL. Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically. Mom and baby currently doing very well.surgery, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: 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: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1. Open reduction and internal screw fixation right fifth metatarsal.,2. Application of short leg splint.,ANESTHESIA:, TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal. The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot. She continued to walk on the foot and found nothing was wrong despite the pain. She was recently seen by Dr. X and was referred to Dr. Y for surgery. The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y. The consent is available on the chart for review. The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL: ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position. A safety strap was placed across her waist for her protection. Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied. After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered in the operative field and a sterile stocking was reflected. Attention was directed to the right fifth metatarsal base. The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal. An avulsion fracture of the right fifth metatarsal base was visualized. The fracture was linear in nature from distal lateral to proximal medial. There appeared to be a pseudoarthrosis on the lateral view. A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve. A linear incision was created with a #10 blade. A #15 blade was used to deepen the incision through the subcutaneous tissue. All small veins traversing the subcutaneous tissue were ligated with electrocautery. Next, using combination of sharp and blunt dissection, the deep fascia was reached. Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade. Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone. The fracture site was not clearly visualized due to bony callus. A #25 gauge needle was introduced into the fracture site under fluoroscopy. The fracture site was easily found. An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone. Next, a small ball burr was used to resect the remaining hypertrophic bone. Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone. Next, a bone clamp was applied and the fracture was reduced. Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally. A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly. All this was done under fluoroscopy. Next, the wound was flushed with copious amounts of sterile saline. The fracture site was found to have rigid compression. The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed. Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion. A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl. Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique. Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique. A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance. A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot. Next, copious amounts of Webril were applied to pad all bony prominences. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits. Next, 4-inch, pre-moulded, well-padded posterior splint was applied. The capillary refill time of the digits was less than three seconds. The patient tolerated the above anesthesia and procedure without complications. After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot. She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone. She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches. She will rest, ice, and elevate her right leg. She is to follow up in the clinic on 08/26/03 at 10:30 a.m.. She was given emergency contact numbers and will call or return if problems arise earlier.orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif

CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.radiology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness

ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.,ALLERGIES:, Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1. Heparin.,2. Albuterol inhaler.,3. Combivent.,4. Aldactone.,5. Doxepin.,6. Xanax.,7. Aspirin.,8. Amiodarone.,9. Tegretol.,10. Synthroid.,11. Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:, Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT: Oropharynx clear.,CV: Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended. Bowel sounds positive.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out.,IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty.,2. History of panic attack, anxiety, depression.,3. Myocardial infarction with stent placement.,4. Hypertension.,5. Hypothyroidism.,6. Subdural hematoma.,7. Seizures.,8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency.,9. Renal insufficiency.,10. Recent pneumonia.,11. O2 requiring.,12. Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.nan

HISTORY OF PRESENT ILLNESS: , The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,PAST CARDIAC HISTORY: , She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy.,MEDICATIONS ON ADMISSION:,1. Multivitamin p.o. daily.,2. Aspirin 325 mg once a day.,3. Lisinopril 40 mg once a day.,4. Felodipine 10 mg once a day.,5. Klor-Con 20 mEq p.o. b.i.d.,6. Omeprazole 20 mg p.o. daily presumably for GERD.,7. MiraLax 17 g p.o. daily.,8. Lasix 20 mg p.o. daily.,ALLERGIES: , PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST.,FAMILY HISTORY:, She states her brother died of an MI suddenly in his 50s.,SOCIAL HISTORY: , She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it.,REVIEW OF SYSTEMS: , She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above.,PHYSICAL EXAM: ,Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.,DIAGNOSTIC STUDIES/LAB DATA: , Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs.,IMPRESSION: ,She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.cardiovascular / pulmonary, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,

REASON FOR VISIT:, The patient presents for a followup for history of erythema nodosum.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States.,In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy.,MEDICATIONS: , Prednisone was stopped. Vitamin D and calcium over the counter, we need to verify that. Colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,FINDINGS:, On physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress. There is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum. Stasis dermatitis changes in both lower extremities present. Mild livedo reticularis is present as well.,There is some periarticular ankle edema as well. Laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a CBC with a white count of 7880, hematocrit of 40.3, and platelets of 228. Her microcytosis and hypochromia has resolved. Her serum electrophoresis does not show a monoclonal abnormality. Her vitamin D levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin D supplementation. This points again towards some ileum pathology. Her ANCA B and C were negative. Her PF3 and MPO were unremarkable. Her endomysial antibodies were negative. Her sed rate at this time were 19. The highest has been 30, but prior to her appointment here was even higher. Her ANA continues to be positive with a titer of 1:40, speckled pattern. Her double-stranded DNA is negative. Her serum immunofixation confirmed the absence of monoclonal abnormality. Her urine immunofixation was not performed. Her IgG, IgA, and IgM levels are normal. Her IgE levels are normal as well. A urinalysis was not performed this time. Her CRP is 0.4. Her tissue transglutaminase antibodies are negative. Her ASCA is normal and anti-OmpC was not tested. Gliadin antibodies IgA is 12, which is in the borderline to be considered equivocal, but these are nonspecific. I am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal. Her B12 levels were 216, which is rather low possibly indicating a B12 deficiency. Her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30. Her TIBC was 345 pointing towards an iron deficiency anemia. I am reminding you that her ACE levels in the past were normal and that she has a microcytosis. Her radiologic workup including a thoracic, abdominal, and pelvic CT did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive. Her pelvic ultrasound showed normal uterus adnexa. Her bladder was normal as well. Subcentimeter inguinal nodes were found. There was no large lytic or sclerotic lesion noted. Her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving Crohn disease. Her capsule endoscopy was limited secondary to rapid transit. There was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum. However, no significant inflammation or bleeding was seen and this could be small bowel crisis. Neither evidence of bleeding or inflammation were seen as well. Specifically, the terminal ileum appeared normal. Recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,ASSESSMENT:, This is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004. She has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers. Since I took over her care, I have not seen a clear-cut erythema nodosum being present. No evidence of synovitis was there. Her serologies apart from an ANA of 1:40 were negative. She has a livedo pattern, which has been worrisome. The issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin B12 as indicated by high methylmalonic and homocystine levels and also iron deficiency. She also has low vitamin D levels, which point towards terminal ileum pathology as well and she had a history of decreased MCV. We never received the x-ray of her hands which she had and she never had a DEXA scan. Lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well. Sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ACE levels were normal. We are going check a PPD to rule out tuberculosis. We are going to order an RVVT and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern. An anti-intrinsic factor will be added as well. Her primary care physician needs to workup the possible B12 and iron deficiency and also the vitamin D deficiency. In the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash. Regarding her heart murmur, we are going to proceed with an echocardiogram. A PPD should be placed as well. In her next appointment, we may fax a requisition for vitamin B replacement.,PROBLEMS/DIAGNOSES:, 1. Recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2. Iron deficiencies, according to iron studies.,3. Borderline B12 with increased methylmalonic acid and homocystine.,4. On chronic steroids; vitamin D and calcium is needed; she needs a DEXA scan.,5. Typical ANCA, per records, were not verified here. ANCA and ASCA were negative and the OmpC was not ordered.,6. Acne.,7. Recurrent arthralgia not present. Rheumatoid factor, CCP negative, ANA 1:40 speckled.,8. Livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today. Needs vaccination for influenza and pneumonia.,9. Vitamin D deficiency. She needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10. Recurrent ankle discomfort which necessitates ankle x-rays.,PLANS:, We can proceed with part of her workup here in clinic, PPD, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies. We can start repleting her vitamin D with __________ weeks of ergocalciferol 50,000 weekly. We can add an RVVT and glycoprotein to her workup in order to rule out any antiphospholipid syndrome. She should be taking vitamin D and calcium after the completion of vitamin D replacement. She should be seen by her primary care physician, have the iron and B12 deficiency worked up. She should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist. Based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum. We are going to add an amylase and lipase to evaluate her pancreatic function, RPR, HIV, __________ serologies. Given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out Whipple disease or celiac disease which can sometimes be associated with erythema nodosum. An anti-intrinsic factor would be added, as I mentioned. I doubt whether the patient has Behcet disease given the absence of oral or genital ulcers. She does not give a history of oral contraceptives or medications that could be related to erythema nodosum. She does not have any evidence of lupus __________ mycosis. Histoplasmosis coccidioidomycosis would be accompanied by other symptoms. Hodgkin disease has probably been ruled out with a CAT scan. However, we are going to add an LDH in future workup. I need to discuss with her primary care physician regarding the need for workup of her vitamin B12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy. The patient will return in 1 month.nan

REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:, Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses. Ears, nose, mouth and throat. The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY: ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps. No joint or muscle pain. No muscle weakness or tenderness. No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS: ,The patient denies easy bruising, skin redness, skin rash, hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC: ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC: ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.consult - history and phy., cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss,

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

PROBLEM LIST:,1. Acquired hypothyroidism.,2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3. Diabetes mellitus.,4. Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1. Levothyroxine 125 micrograms p.o. once daily.,2. CPAP.,3. Glucotrol.,4. Avandamet.,5. Synthroid.,6. Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI. She is not reporting polyuria, polydipsia or polyphagia. She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL: She is an overweight, very pleasant woman, in no acute distress. VITAL SIGNS: Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. NECK: Reveals well healed surgical scar in the anteroinferior aspect of the neck. There is no palpable thyroid tissue noted on this examination today. There is no lymphadenopathy. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 is auscultated. EXTREMITIES: Deep tendon reflexes 2+/4 without a delayed relaxation phase. No fine resting tremor of the outstretched upper extremity. SKIN, HAIR, AND NAILS: All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following: Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1. Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2. Plan to continue following thyroglobulin levels.,3. Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4. Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5. Plan today is to repeat her thyroid function studies. This case was discussed with Dr. X and the recommendation. We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less. Therefore, labs have been drawn. We plan to see the patient back in approximately 6 months or sooner. A repeat body scan will not been done, the one in 03/06 was negative.soap / chart / progress notes, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism,

NERVE CONDUCTION TESTING AND EMG EVALUATION,1. Right median sensory response 3.0, amplitude 2.5, distance 100.,2. Right ulnar sensory response 2.1, amplitude 1, distance 90.,3. Left median sensory response 3.0, amplitude 1.2, distance 100.,4. Left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5. Right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6. Right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,NEEDLE EMG TESTING,1. ,RIGHT BICEPS:, Fibrillations 0, fasciculations occasional, positive waves 0. Motor units, increased needle insertional activity and mild decreased number of motor units firing.,2. ,RIGHT TRICEPS:, Fibrillations 1+, fasciculations occasional to 1+, positive waves 1+. Motor units, increased needle insertional activity and decreased number of motor units firing.,3. ,EXTENSOR DIGITORUM:, Fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4. ,FIRST DORSAL INTEROSSEOUS: , Fibrillations 2+, fasciculations 1+, positive waves 2+. Motor units, decreased number of motor units firing.,5. ,RIGHT ABDUCTOR POLLICIS BREVIS:, Fibrillations 1+, fasciculations 1+, positive waves 0. Motor units, decreased number of motor units firing.,6. , FLEXOR CARPI ULNARIS:, Fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+. Motor units, decreased number of motor units firing.,7. ,LEFT FIRST DORSAL INTEROSSEOUS:, Fibrillations 1+, fasciculations 1+, positive waves occasional. Motor units, decreased number of motor units firing.,8. ,LEFT EXTENSOR DIGITORUM:, Fibrillations 1+, fasciculations 1+. Motor units, decreased number of motor units firing.,9. ,RIGHT VASTUS MEDIALIS:, Fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+. Motor units, decreased number of motor units firing.,10. ,ANTERIOR TIBIALIS: , Fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+. Motor units, increased proportion of polyphasic units and decreased number of motor units firing. There is again increased needle insertional activity.,11. ,RIGHT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 1+. Motor units, marked decreased number of motor units firing.,12. ,LEFT GASTROCNEMIUS:, Fibrillations 1+, fasciculations 1+, positive waves 2+. Motor units, marked decreased number of motor units firing.,13. ,LEFT VASTUS MEDIALIS: , Fibrillations occasional, fasciculations occasional, positive waves 1+. Motor units, decreased number of motor units firing.,IMPRESSION: nan