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S - ,This patient has reoccurring ingrown infected toenails. He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border. The right great toenail is ingrown on the lateral nail border only. There is mild redness and granulation tissue growing on the borders of the toes. One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe. These lesions measure 0.5 cm in diameter each. I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1. Onychocryptosis.,soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

REASON FOR ADMISSION:, Intraperitoneal chemotherapy.,HISTORY: , A very pleasant 63-year-old hypertensive, nondiabetic, African-American female with a history of peritoneal mesothelioma. The patient has received prior intravenous chemotherapy. Due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy. She had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her. Therefore, on the last hospitalization for IP chemo, she was switched to Taxol. The patient since her last visit has done relatively well. She had no acute problems and has basically only chronic difficulties. She has had some decrease in her appetite, although her weight has been stable. She has had no fever, chills, or sweats. Activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease. She had a recent CT scan of the chest and abdomen. The report showed the following findings. In the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve. There was one mildly enlarged mediastinal lymph node. Several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific. No pulmonary masses were noted. In the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland. On the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted. There were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study. A hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst. It was unchanged from February and measured 9 mm. There was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable. Mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them. There was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm. In the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter. No suspicious osseous lesions were noted.,CURRENT MEDICATIONS: , Norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., Levoxyl 75 mcg p.o. daily, Phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, Ventolin HFA 2 puffs q.6h. p.r.n., Plavix 75 mg p.o. daily, Norvasc 10 mg p.o. daily, Cymbalta 60 mg p.o. daily, and Restoril 30 mg at bedtime as needed for sleep.,ALLERGIES: , THE PATIENT STATES THAT ON OCCASION LORAZEPAM DOSE PRODUCE HALLUCINATIONS, AND SHE HAD DIFFICULTY TOLERATING ATIVAN.,PHYSICAL EXAMINATION,VITAL SIGNS: The patient's height is 165 cm, weight is 77 kg. BSA is 1.8 sq m. The vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an SpO2 of 100% on room air.,GENERAL: She is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time. She is anicteric.,HEENT: EOM is full. Pupils are equal, round, reactive to light and accommodation. Disc margins are unremarkable as are the ocular fields. Mouth and pharynx within normal limits. The TMs are glistening bilaterally. External auditory canals are unremarkable.,NECK: Supple, nontender without adenopathy. Trachea is midline. There are no bruits nor is there jugular venous distention.,CHEST: Clear to percussion and auscultation bilaterally.,HEART: Regular rate and rhythm without murmur, gallop, or rub.,BREASTS: Unremarkable.,ABDOMEN: Slightly protuberant. Bowel tones are present and normal. She has no palpable mass, and there is no hepatosplenomegaly.,EXTREMITIES: Within normal limits.,NEUROLOGICAL: Nonfocal.,DIAGNOSTIC IMPRESSION,1. Intraperitoneal mesothelioma, partial remission, as noted by CT scan of the abdomen.,2. Presumed left lower pole kidney hemorrhagic cyst.,3. History of hypertension.,4. Type 1 bipolar disease.,PLAN: , The patient will have appropriate laboratory studies done. A left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney. Interventional radiology will access for ports in the abdomen. She will receive chemotherapy intraperitoneally. The plan will be to use intraperitoneal Taxol.hematology - oncology, chemo, taxol, intraperitoneal mesothelioma, peritoneal mesothelioma, intravenous chemotherapy, adrenal gland, hemorrhagic cyst, peritoneal, intraperitoneal, hemorrhagic, mesothelioma, chemotherapy,

PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE:, Stable, extubated, and transferred to the recovery room in stable condition.,INDICATIONS FOR PROCEDURE: ,The patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate. The patient has undergone cleft lip repair, and she is here today for her cleft palate operation. We have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries. We will proceed with surgery.,DETAILS OF THE PROCEDURE:, The patient was taken into the operating room, placed in the supine position, and general anesthetic was administered. A prophylactic dose of antibiotics was given. The patient proceeded to have bilateral PE tube placement by Dr. X, from Ear, Nose, and Throat Surgery. After he was done with his procedure, the head of the bed was turned 90 degrees. The patient was positioned with a shoulder roll and doughnut. A Dingman retractor was placed. The operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 mL, and then, I proceeded with the prepping and draping. The patient was prepped and draped. I proceeded to do the palate repair. The nature of the palate repair was done in the same way on the both sides. I will describe one side. The other side was done exactly in the same manner. The 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked. This triangle of nasal mucosa was removed and excised. This was done on both uvulas. Then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa. A 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better. Once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa. Then, I proceeded to place an incision at the alveolopalatal junction with the help of 15-blade. The incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap. Then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed. Hemostasis was achieved with help of electrocautery and Surgicel. The mucoperiosteal flap was retracted posteriorly with the help of a freer elevator. The greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap. Then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle. The pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially. This procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together. At this point, the decision was made to proceed with vomer flaps. The flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book. The incision was done with a 15C blade. The vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate. This was approximated on both sides with 5-0 chromic running and interrupted stitches, and I proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic. Then 2 stitches of 4-0 Vicryl were applied to the soft palate in the Delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate. The remaining part of the soft palate was placed together with 4-0 Vicryl and 4-0 chromic interrupted stitches. The throat pack was removed. The palate was cleaned. The Dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of Tegaderm. The patient tolerated the procedure without complications. BSS is applied to the eye after removing the Tegaderm. I was present and participated in all aspects of the procedure. The sponge, needle, and instrument count were completed at the end of the procedure. The patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.surgery, bilateral cleft, cleft lip, oral mucosa, hard palate, soft palate, vomer flaps, mucoperiosteal flap, nasal mucosa, flaps, cleft, mucosa, palate, mucoperiosteal, bilateral, nasal,

HISTORY OF PRESENT ILLNESS:, Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass. The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss. At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:, Significant for hypertension, for which the patient takes Norvasc and Lopressor for. She also suffers from high cholesterol and is on lovastatin for this. She has depression, for which she takes citalopram. She also stated that she had a DVT in the past prior to her hysterectomy. She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones. She also had a hysterectomy in 1994 secondary to hemorrhage. The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker. She is married, with 2 children aged 22 and 28. She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY: ,Significant for high blood pressure and diabetes as well as cancer on her father side. He did pass away from congestive heart failure. Mother suffers from high blood pressure, cancer, and diabetes. Her mother has passed away secondary to cancer. She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling. The patient also wears glasses for vision and has dentures. She does complain of shortness of breath with exertion. She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease. She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION: ,The patient is a well-nourished, well-developed female, in no distress. Eye Exam: Pupils equal and reactive to light. Extraocular motions are intact. Neck Exam: No cervical lymphadenopathy. Midline trachea. No carotid bruits. Nonpalpable thyroid. Neuro Exam: Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. Lung Exam: Clear breath sounds without rhonchi or wheezes. Cardiac Exam: Regular rate and rhythm without murmur or bruits. Abdominal Exam: Positive bowel sounds. Soft, nontender, obese, and nondistended abdomen. Lap cholecystectomy scars noted. No obvious hernias. No organomegaly appreciated. Lower extremity Exam: Edema 1+. Dorsalis pedis pulses 2+.,ASSESSMENT: ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy. Also the patient will meet with the dietitian and psychologist as per her usual routine. I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.consult - history and phy., jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,

PROCEDURE: , Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.,INDICATION: , The patient is a 51-year-old female with back pain referring into the right leg.,RISKS VERSUS BENEFITS: , The risks and benefits were discussed with the patient prior to the procedure. She agrees to accept the risks and signs a written consent to proceed with the procedure.,DESCRIPTION OF PROCEDURE: , The patient was placed prone on the table. The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze. The subcutaneous intramuscular and interligamentous region was anesthetized with 4% lidocaine.,A 3-1/2-inch 20-gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina. Once the lamina was detected, the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space.,EPIDUROGRAM: , Omnipaque 300 1.5 mL was placed just to the right of the midline. This was viewed on the AP and lateral projections. It showed typical epidural spread pattern with good cephalad and caudad flow, and the flow was unrestricted.,Depo-Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5-S1.,The patient tolerated the procedure well without procedural complications. She will follow up with me in the office in the next few weeks to monitor her response to the injection.pain management, epidural steroid injection, fluoroscopic guidance, depo medrol, injection

PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon. At this point, stool occupied the lumen, preventing further passage. The colon distal to this was well cleaned out and easily visualized. The mucosa was normal throughout the regions examined. Numerous diverticula were seen. There was no blood or old blood or active bleeding. A retroflexed view of the anorectal junction showed no hemorrhoids. He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Sigmoid and left colon diverticulosis.,2. Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3. The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. If there is further bleeding, a full colonoscopy is recommended.gastroenterology, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon

ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, urology, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst

PREOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:, The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. After this, the patient was then prepped and draped with Hibiclens. A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. After this, the patient's anterior trachea was then identified and cleaned with pusher. After this, the cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker. After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage. After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap. After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. The patient will have the stent guidewire removed with a scoop catheter 11 cm placed.surgery, oxygen dependency, chronic obstructive pulmonary disease, tracheostomy, scoop procedure, nasal cannula, scoop procedure fasttract, thyroid isthmus, cricoid cartilage, isthmus, oxygen, dependency, scoop, cartilages

PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:, Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1. Tympanostomy and tube placement.,2. Adenoidectomy.,ANESTHESIA: ,General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, prepped and draped in the usual fashion. After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx. With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior. The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made. Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle. Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.ent - otolaryngology, robinson catheters, palate, tongue, tympanostomy, adenoidectomy, chronic otitis media, oral cavity, adenotonsillar hypertrophy, tube placement, hypertrophy, nasopharynx, adenotonsillar,

PRE-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,POST-OP DIAGNOSIS:, Osteoporosis, pathologic fractures T12- L2 with severe kyphosis.,PROCEDURE:,1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.,2. Bone biopsy (medically necessary).,ANESTHESIA:, General,COMPLICATIONS:, None,BLOOD LOSS:, Minimal,INDICATIONS:, Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).,Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures.,PROCEDURE:, The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.,At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.,Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.,Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal.orthopedic, osteoporosis, pathologic fractures, kyphosis, bone cement, balloon kyphoplasty, kyphon balloon kyphoplasty, bone biopsy, kyphon, insertion of kyphon, ap and lateral, vertebral body, kyphon balloon, anterior cortex, vertebral, body, fractures, insertion, bone, kyphoplasty, guide, balloon, pedicles, cortex, positioned, therapy

PREOPERATIVE DIAGNOSIS:, End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA: ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:, Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY: ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition. She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein. After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room, placed supine on the operating table. After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion. A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife. The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues. This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion. Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection. The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein. There was noted to be excellent flow through the vein. A pocket was then created just lateral to the incision in the subcutaneous tissue. The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures. The bed of dissection of the basilic vein was then treated with fibrin sealant. The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion. The skin was closed using 4-0 Monocryl suture for a subcuticular stitch. Dermabond was applied to the incision. Again, there was noted to be good palpable thrill throughout the superficialized vein. The patient was then awakened, and taken to the recovery room in stable condition.surgery, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,

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

EXAM: , Bilateral diagnostic mammogram and right breast ultrasound.,History of palpable abnormality at 10 o'clock in the right breast. Family history of a sister with breast cancer at age 43.,TECHNIQUE: , CC and MLO views of both breasts were obtained. Spot compression views of the palpable area were also obtained. Right breast ultrasound was performed. Comparison is made with mm/dd/yy.,FINDINGS: , The breast parenchymal pattern is stable with heterogeneous scattered areas of fibroglandular tissue. No new mass or architectural distortion is evident. Asymmetric density in the upper outer posterior left breast and a nodule in the upper outer right breast are unchanged. There is no suspicious cluster of microcalcifications.,Directed ultrasonography of the upper outer quadrant of the right breast revealed no cystic or hypoechoic solid mass.,IMPRESSION:,1. Stable mammographic appearance from mm/dd/yy.,2. No sonographic evidence of a mass at 10 o'clock in the right breast to correspond to the palpable abnormality. The need for further assessment of a palpable abnormality should be determined clinically.,BIRADS Classification 2 - Benignobstetrics / gynecology, diagnostic mammogram, diagnostic, mammogram, ultrasound, palpable

REASON FOR CONSULTATION: , Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.,HISTORY OF PRESENT ILLNESS:, This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.,PAST MEDICAL HISTORY:,1. Coronary artery disease, status post stent placement two years ago.,2. Diabetes mellitus for the last 12 years.,3. Hypertension.,4. End-stage renal disease.,5. History of TIA in the past.,PAST SURGICAL HISTORY:,1. As mentioned above.,2. Cholecystectomy.,3. Appendectomy.,4. Right IJ PermaCath placement.,5. AV fistula graft in the right wrist.,PERSONAL AND SOCIAL HISTORY:, He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.,FAMILY HISTORY: , Noncontributory.,ALLERGIES: ,No known drug allergies.,MEDICATIONS AT HOME: , Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.,PHYSICAL EXAMINATION,GENERAL: He is alert, seems to be in no apparent distress.,VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.,HEENT: Atraumatic and normocephalic.,NECK: No JVD, no thyromegaly, supra and infraclavicular lymphadenopathy.,LUNGS: Clear to auscultation. Air entry bilateral equal.,HEART: S1 and S2. No pericardial rub.,ABDOMEN: Soft and nontender. Normal bowel sounds.,EXTREMITIES: No edema.,NEUROLOGIC: The patient is alert without focal deficit.,LABORATORY DATA:, Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.,IMPRESSION:,1. End-stage renal disease, plan for dialysis today.,2. Diabetes mellitus.,3. Chest pain for coronary angiogram today.,4. Hypertension, blood pressure stable.,PLAN: , Currently follow the patient. Dr. Z is going to assume the care.nan

PROCEDURES PERFORMED:,1. DDDR permanent pacemaker.,2. Insertion of a steroid-eluting screw in right atrial lead.,3. Insertion of a steroid-eluting screw in right ventricular apical lead.,4. Pulse generator insertion, model Sigma.,SITE: , Left subclavian vein access.,INDICATION: , The patient is a 73-year-old African-American female with symptomatic bradycardia and chronotropic incompetence with recurrent heart failure and symptoms of hypoperfusion, and for a Class 2a indication for a permanent pacemaker was ascertained.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,Risks, benefits, and alternatives of the procedure were all explained in detail to the patient and the patient's family at length. They all consented for the procedure, and the consent was signed and placed on the chart.,PROCEDURE: , The patient was taken to cardiac cath lab where she was monitored throughout all procedure. The area of the left pectoral deltoid and subclavian area was sterilely prepped and draped in the usual manner. We also scrubbed for approximately eight minutes. Using lidocaine with epinephrine, the area of the left pectoral deltoid region and subclavian area was then fully anesthetized. Using an #18 gauge Cook needle, the left subclavian vein was cannulated at two separate sites without difficulty, where two separate guidewires were inserted into the left subclavian vein. The Cook needles were removed. Then the guidewires were secured in place with hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectodeltoid groove, where the skin was dissected and blunted on to the pectoralis major muscle. The skin was then undermined making a pocket for the generator. The guidewires were then tunneled through the performed pocket. Subsequently, the atrial and ventricular leads were inserted through each one of the Cordis separately and respectively. Initially, the ventricular lead was inserted, where a Cordis sheath was placed and the guidewire was removed. After the thresholds and appropriate position was obtained for the ventricular lead, the Cordis sheath was then inserted for the atrial lead. After the atrial lead was inserted and appropriately placed and thresholds were obtained, the Cordis was removed and then both leads were sutured in place with pectoralis major muscle with #1-0 silk suture. The leads were then connected to a pulse generator. The pocket was then irrigated and cleansed, where then the leads and the generators were inserted into that pocket. The subcutaneous tissue was then closed with gut sutures and the skin was then closed with #4-0 polychrome sutures using a subcuticular uninterrupted technique. The area was then cleansed and dry. Steri-Strips and pressure dressing were applied. The patient tolerated the procedure well. There were no complications.,Information on the pacemaker:,The implanted device are as follows:,PULSE GENERATOR,Model Name: Sigma.,Model #: SDR203.,Serial #: 123456.,ATRIAL LEAD,Model #: 4568-45 cm.,Serial #: 123456.,RIGHT VENTRICULAR APICAL STEROID-eluting SCREW IN LEAD:,Model #: 4068-52 cm.,Serial #: 123456.,STIMULATION THRESHOLDS ARE AS FOLLOWS:,The right atrial chamber polarity is bipolar, pulse width is 0.50 milliseconds, 1.5 volts of voltage, 3.7 milliamps of current, 557 ohms of impedance, and P-wave sensing of 3.3 millivolts.,The right ventricular polarity is bipolar, pulse width is 0.50 milliseconds, 0.7 volts of voltage, 1.4 milliamps of current, impedance of 700 ohms, and R-wave sensing of 14 millivolts.,The brady parameter settings were set as follows:,The atrial and ventricular appendages were set at 3.5 volts with 0.4 milliseconds of pulse width, atrial sensitivity of 0.5 with 180 milliseconds of blanking. Ventricular sensitivity was set at 2.8 with 28 milliseconds of blanking. The pacing mode was DDDR, mode switch was on lower rate of 70 and upper rate of 130.,The patient tolerated the procedure well. There were no complications. The patient went to Recovery in satisfactory condition. Family was updated. Orders are all in the chart. Please see orders.,Again, thank you for allowing to participate in this care.nan

PREOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1. Chronic otitis media with effusion.,2. Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA: ,Total IV general mask airway.,ESTIMATED BLOOD LOSS: ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:, The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:, The patient was brought to the operative suite by Anesthesia. The patient was placed on the operating table in supine position. After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction. After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma. A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents. A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep. Cortisporin Otic drops were placed followed by cotton balls. Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed. The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane. The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels. A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep. After this, the patient had Cortisporin Otic drops followed by cotton balls placed. The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well. The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.ent - otolaryngology, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy

PROCEDURES PERFORMED:, Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:, Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother. The patient was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation. Approximately 7 mL was injected on the right side and 5 mL on the left side. At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol. The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation. Approximately 5 mL of 5% phenol was injected in this location. Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation. Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered.neurosurgery, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol

PREOPERATIVE DIAGNOSIS: ,Carcinoma of the prostate, clinical stage T1C.,POSTOPERATIVE DIAGNOSIS: , Carcinoma of the prostate, clinical stage T1C.,TITLE OF OPERATION: , Cystoscopy, cryosurgical ablation of the prostate.,FINDINGS: ,After measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone. Because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,OPERATION IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position. Full bowel prep had been obtained prior to the procedure. After performing flexible cystoscopy, a Foley catheter was placed per urethra into the bladder. Next, the ultrasound probe was placed into the stabilizer and advanced into the rectum. An excellent ultrasound image was visualized of the entire prostate, which was re-measured. Next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement. Then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate. Ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra. Repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed. The CMS urethral warmer was then passed per urethra into the bladder, and flow instituted. After placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior. The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself. Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature. The urethral warmer was left on after the needles were removed and the patient brought to the recovery room. The patient tolerated the procedure well and left the operating room in stable condition.urology, carcinoma of the prostate, ablation, cystoscopy, cryosurgical ablation, prostate, ultrasound, cryosurgical, urethra,

PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1. Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2. Bone grafts.,3. Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:, None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis. We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft. We have discussed risks and benefits. Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection. The parents understand, decide to proceed with surgery. Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position. General anesthetic was administered. Prophylactic dose of antibiotic was given. Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees. The patient was once more positioned and padded in the usual manner. The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane. The subgaleal plane was developed and reflected anteriorly and slightly posteriorly. Hemostasis achieved with electrocautery. Raney clips were applied to both flaps to prevent significant bleeding. Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure. I assisted her and this will be described in a different operative report. Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor. The osteotomies were done with the Midas and some irrigation. There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim. This was done on both sides. Hemostasis achieved with bone wax and electrocautery. Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements. On the left side, there was a minor fracture to the superior orbital rim that was plated. The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim. The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches. The forehead flaps were attached with the help of absorbable mesh. The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws. Hemostasis was checked. The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut. Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net. The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition. I was present and participated in all aspects of the procedure. Sponge, needle, and instrument counts were completed at the end of the procedure.cosmetic / plastic surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead,

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

PREOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Large recurrent right pleural effusion.,PROCEDURE:,1. Conscious sedation.,2. Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:, None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:, After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. Vital signs were taken. These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV. After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive. The patient tolerated the procedure well. She did complain of up to a 7/10 pain, but quickly this was brought under control. The chest tube was unclamped. Now, the patient will be left to rest and she will get a chest x-ray in the morning.cardiovascular / pulmonary, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube

CHIEF COMPLAINT / REASON FOR THE VISIT:, Patient has been diagnosed to have breast cancer.,BREAST CANCER HISTORY:, Patient presented with the following complaints: Lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. The lump is painless and the skin over the lump is normal. Patient denies any redness, warmth, edema and nipple discharge. Patient had a mammogram recently and was told to have a mass measuring 2 cm in the UOQ and of the left breast. Patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,PATHOLOGY:, Infiltrating ductal carcinoma, Estrogen receptor 56, Progesterone receptor 23, S-phase fraction 2., Her 2 neu 0 and all nodes negative.,STAGE:, Stage I.,TNM STAGE:, T1, N0 and M0.,SURGERY:, S/P lumpectomy left breast and Left axillary node sampling. Patient is here for further recommendation.,PAST MEDICAL HISTORY:, Osteoarthritis for 5 years. ASHD for 10 years. Kidney stones recurrent for 10 years.,SCREENING TEST HISTORY:, Last rectal exam was done on 10/99. Last mammogram was done on 12/99. Last gynecological exam was done on 10/99. Last PAP smear was done on 10/99. Last chest x-ray was done on 10/99. Last F.O.B. was done on 10/99-X3. Last sigmoidoscopy was done on 1998. Last colonoscopy was done on 1996.,IMMUNIZATION HISTORY:, Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996.,FAMILY MEDICAL HISTORY:, Father age 85, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 78. No brothers and sisters. 1 son healthy at age 54.,PAST SURGICAL HISTORY:, Appendectomy. Biopsy of the left breast 1996 - benign.nan

PREOPERATIVE DIAGNOSIS: ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. He was placed into a well-molded splint after reduction was performed in the emergency department. Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure. The right upper extremity was prepped and draped in a sterile fashion. A 5-cm incision was made over the flexor carpi radialis of the right wrist. The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. Next, a reduction was performed placing the distal fragment into appropriate alignment. This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. An Acumed Accu-lock plate was placed along the volar aspect of the distal radius. This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment. A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. Two distal locking screws were placed along the plate itself. The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. AP and lateral views were taken of these screw placements again. None of these screws were into the joint and all had appropriate length into the dorsal cortex. Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. Bicortical purchase was appreciated and no screws were placed into the joint. The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. The patient tolerated the procedure well.surgery, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist

SUBJECTIVE:, This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema. The patient’s mom is from Tanzania. The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her. The patient is a well-developed baby. Appears stated age. Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies.,CURRENT MEDICATIONS:, None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:, Atopic eczema.,TREATMENT:,1. Discussed condition and treatment with Mom.,2. Continue bathing twice a week.,3. Discontinue hot soapy water.,4. Discontinue Elidel for now.,5. Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch. We will see her in one month if not better otherwise on a p.r.n. basis. Send a letter to ABC Practice program.dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,

EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE: ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS: ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. The remainder of the lung parenchyma is clear. There is no pneumothorax or effusion. The heart size and pulmonary vessels appear unremarkable. There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.radiology, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest

CC:, Stable expressive aphasia and decreased vision.,HX:, This 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. She was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. One month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. A HCT (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. Skull X-rays showed deviation of the pineal to the right. She was transferred to UIHC and was noted to have a normal neurologic exam (per Neurosurgery note). Angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. She under went left temporal craniotomy and "complete resection" of the tumor which on pathologic analysis was consistent with a meningioma.,The left sphenoid wing meningioma recurred and was excised 9/25/84. There was regrowth of this tumor seen on HCT, 1985. A 6/88 HCT revealed the left sphenoid meningioma and a new left tentorial meningioma. HCT in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. On 2/14/91 she presented with increasing lethargy and difficulty concentrating. A 2/14/91, HCT revealed increased size and surrounding edema of the left frontal meningioma. The left frontal and temporal meningiomas were excised on 2/25/91. These tumors all recurred and a left parietal lesion developed. She underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. The weakness partially resolved and though the speech improved following resection it did not return to normal. In May 1992 she experienced 3 tonic-clonic type seizures, all of which began with a Jacksonian march up the RLE then RUE before generalizing. Her Phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. On 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. Postoperatively she developed worsened right sided weakness and expressive aphasia. The weakness and aphasia improved by 3/93, but never returned to normal.consult - history and phy., sphenoid wing meningioma, sphenoid wing, expressive aphasia, meningiomas, aphasia, sphenoidNOTE,: 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:, C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms. Her MRI showed stenosis at portion of C4 to C6. I discussed the procedure as well as risks and complications. She wishes to proceed with surgery. Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE: ,The patient was taken to the operating room on 10/02/2007. She was intubated for anesthesia. TEDS and boots as well as Foley catheter were placed. She was placed in a supine position with her neck in neutral position. Appropriate pads were also used. The area was prepped and draped in usual sterile fashion. Preoperative localization was taken. _____ not changed. Incision was made on the right side in transverse fashion over C5 vertebral body level. This was made with a #10 blade knife and further taken down with pickups and scissors. The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine. Intraoperative x-ray was taken. Longus colli muscles were retracted laterally. Caspar retractors were used. Intraoperative x-ray was taken. I first turned by attention at C5-C6 interspace. This was opened with #15 blade knife. Disc material was taken out using pituitary as well as Kerrison rongeur. Anterior aspects were taken down. End plates were arthrodesed using curettes. This was done under distraction. Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur. Bilateral foraminotomies were done. At this point, I felt that there was a good decompression. The foramen appeared to be opened. Medtronic cage was then encountered and sent few millimeters. This was packed with demineralized bone matrix. The distraction was then taken down. The cage appeared to be strong. This procedure was then repeated at C4-C5. A 42-mm AcuFix plate was then placed between C4 and C6. This was carefully screwed and locked. The instrumentation appeared to be strong. Intraoperative x-ray was taken. Irrigation was used. Hemostasis was achieved. The platysmas was closed with 3-0 Vicryl stitches. The subcutaneous was closed with 4-0 Vicryl stitches. The skin was closed with Steri-strips. The area was clean and dry and dressed with Telfa and Tegaderm. Soft cervical collar was placed for the patient. She was extubated per anesthesia and brought to the recovery in stable condition.orthopedic, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,

ADMISSION DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1. Severe menometrorrhagia unresponsive to medical therapy.,2. Severe anemia.,3. Symptomatic fibroid uterus.,4. Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:, None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively. On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT: ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed. The patient tolerated all procedures well. On the 1st postoperative day, the patient was afebrile and all vital signs were stable. On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet. On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness. On the 5th postoperative day, the patient was afebrile. Vital signs were stable. The patient was tolerating a diet and ambulating without difficulty. The patient was desirous of going home. The patient denied any abdominal pain or flank pain. The patient had minimal incisional wound tenderness. The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:, Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks. Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily. The patient is to return on Wednesday 6/17/2009 for removal of staples. The patient was given a full explanation of her clinical condition. The patient was given full and complete postoperative and discharge instructions. All her questions were answered.obstetrics / gynecology, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal,

SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was following it accurately. She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well. Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off. However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:, Weight is 275 pounds. Food records were reviewed.,ASSESSMENT:, The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago. I did carefully review her food records and evaluated calories consumed. While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected. Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well. She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates. While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction. We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:, A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat. This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack. This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack. We have eliminated the morning snack. The patient will now track the grams of fat in her meats as well as added fats. Her goal for total fats over the course of the day is no more than 42 grams of fat per day. This was a half hour consultation. We will plan to see the patient back in one month for support.consult - history and phy., hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight

REASON FOR VISIT: ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:, The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional. She is not able to use the walker because her left arm is so weak. She has not been having any headaches. She has had a significant decrease in appetite. She is known to have lung cancer, but Ms. Wilson does not know what kind. According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung. The last note I have to evaluate is from October 2008. CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion. I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand. She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:, Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS: ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED: ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE: ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter. The patient' daughter remained present throughout the procedure. The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture. During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort. The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table. Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT: ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.nan

DISCHARGE DIAGNOSES:,1. Gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. History of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. History of urinary tract infections of pyelonephritis.,OPERATIONS PERFORMED: , Chest x-ray July 24, 2007, that was normal. Transesophageal echocardiogram July 27, 2007, that was normal. No evidence of vegetations. CT scan of the abdomen and pelvis July 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. There were 2-3 additional tiny cysts in the right lobe. The remainder of the CT scan was normal.,HISTORY OF PRESENT ILLNESS: , Briefly, the patient is a 26-year-old white female with a history of fevers. For further details of the admission, please see the previously dictated history and physical. ,HOSPITAL COURSE:, Gram-negative rod bacteremia. The patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and Osler nodes on her fingers. The patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. The microbiology laboratory stated that the Gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. The patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. We did a CT scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. There was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. I spoke with Dr. XYZ of infectious diseases, and Dr. XYZ asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in Utah. Much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. I ordered tularemia and leptospirosis serologies on the advice of Dr. XYZ, and as of the day after discharge, the results of the microbiology still are not back yet. The patient, however, appeared to be responding well to levofloxacin. I gave her a 2-week course of 750 mg a day of levofloxacin, and I have instructed her to follow up with Dr. XYZ in the meantime. Hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. A thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. In addition, I told the patient that it would be my recommendation to get rid of the rats. I told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. I told her very clearly that she should, indeed, get rid of the animals. The patient seemed reluctant to do so at first, but I believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following., ,DISPOSITION,DISCHARGE INSTRUCTIONS: , Activity is as tolerated. Diet is as tolerated.,MEDICATIONS: , Levaquin 750 mg daily x14 days.,Followup is with Dr. XYZ of infectious diseases. I gave the patient the phone number to call on Monday for an appointment. Additional followup is also with Dr. XYZ, her primary care physician. Please note that 40 minutes was spent in the discharge.discharge summary, abdomen and pelvis, gram negative rod, congenital genitourinary, genitourinary abnormalities, transesophageal echocardiogram, infectious diseases, leptospirosis serologies, gram negative, ct scan, identification, infections, levofloxacin, additional, discharge

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: ,Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.,Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1. Negative for pulmonary arterial embolism.,2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3. Cardiomegaly with mitral valvular calcifications.,4. Postsurgical changes of a left upper lobectomy.,5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.cardiovascular / pulmonary, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,

PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone. Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:, minimal.orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,

We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor.,So her discharge meds are as follows:,1. Coreg 6.25 mg b.i.d.,2. Simvastatin 40 mg nightly.,3. Lisinopril 5 mg b.i.d.,4. Protonix 40 mg a.m.,5. Aspirin 160 mg a day.,6. Lasix 20 mg b.i.d.,7. Spiriva puff daily.,8. Albuterol p.r.n. q.i.d.,9. Advair 500/50 puff b.i.d.,10. Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks. She is to follow up with Dr. X before that.soap / chart / progress notes, chest pain, respiratory insufficiency, chronic lung disease, bronchospastic angina, insufficiency, chest, angina, respiratory, bronchospastic

PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop. The preparation was good and all surfaces were well seen. The hypopharynx was normal with no evidence of inflammation. The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate. The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's. Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food. The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration. Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation. The scope was withdrawn and the patient was sent to recovery room. She tolerated the procedure well.,FINAL DIAGNOSES:,1. Normal post-gastric bypass anatomy.,2. No evidence of inflammation or narrowing to explain her symptoms.gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation

DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:, None.,FINDINGS: ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position. After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined. She was found to have an anteverted uterus and no adnexal mass. She was prepped and draped in the usual fashion. The Foley catheter was placed. A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife. A Veress needle was inserted into the abdomen. Intraperitoneal location was verified with approximately 10 cc of sterile solution. A pneumoperitoneum was created. The Veress needle was then removed, and a trocar was inserted directly without difficulty. Intraperitoneal location was verified visually with the laparoscope. There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization. An attempt was made to close the fascia with a figure-of-eight suture. However, this was felt to be more subcutaneous. The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.surgery, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope

PREOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0).,POSTOPERATIVE DIAGNOSES: ,1. Large herniated nucleus pulposus, C5-C6 with myelopathy (722.21).,2. Cervical spondylosis.,3. Cervical stenosis, C5-C6 secondary to above (723.0), with surgical findings confirmed.,PROCEDURES: , ,1. Anterior cervical discectomy at C5-C6 with spinal cord and spinal canal decompression (63075).,2. Anterior interbody fusion at C5-C6, (22554) utilizing Bengal cage (22851).,3. Anterior instrumentation for stabilization by Uniplate construction, C5-C6, (22845); with intraoperative x-ray times two.,ANESTHESIA: , General.,SERVICE: , Neurosurgery.,OPERATION: ,The patient was brought into the operating room, placed in a supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case. A prominent anterior osteophyte at C5-C6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved. This allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to Pathology for a permanent section. Residual osteophytes and disc fragments were removed with 1 and 2-mm micro Kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well. A hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status. At no time during the case was evidence of CSF leakage, and hemostasis was readily achieved with pledgets of Gelfoam subsequently removed with copious amounts of antibiotic irrigation. Once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a Bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied. Further stability was added nonetheless with an appropriate size Uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner. The wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 Vicryl, and the skin with a subcuticular stitch of 4-0 Vicryl, and this was Steri-Stripped for reinforcement, and a sterile dressing was applied, incorporating a Penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner. Once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,At the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.orthopedic, herniated nucleus pulposus, myelopathy, cervical spondylosis, cervical stenosis, anterior instrumentation, uniplate, decompression, anterior cervical discectomy, spinal cord, spinal canal, sterile dressing, interbody fusion, bengal cage, interbody, cervical, anterior, discectomy,

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.emergency room reports, hypokalemia, shortness of breath, atrial tachycardia, sinus rhythm, hip fracture, atrial, tachycardia, rhythm, apcs, cardiac, regurgitation, aortic, hypertension, pulmonary,

Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero.consult - history and phy., pain management, opioid dependence, patrick's test, behavioral evaluation, cognitive impairment, low back syndrome, motor strength, pain control, physical therapy, radiculopathy, spinal cord stimulation, activities of daily living, neurological exam, laminectomy, hearing, diabetes, muscle, syndrome,

S: , The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006.,PRIMARY MEDICAL HISTORY:, Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation.,MEDICATIONS:, Refer to chart.,O: , The patient presents in wheelchair, verbal and alert. Vascular: He has absent pedal pulses bilaterally. Trophic changes include absent hair growth and dystrophic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings include temperature change and edema +2. Nails: Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left.,A:,1. Dystrophic nails.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,4. Diabetes.,P: ,Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided. The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails.podiatry, debrided, nails, dystrophic nails, dystrophic

PREOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1. Pathologic insufficiency.,2. Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1. Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2. Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:, None.,SURGICAL INDICATIONS:, The patient is an 80-year-old female who had previous history of compression fractures. She had recently undergone an additional compression fracture of the T8 vertebrae. She was in extreme pain. This pain interfered with activities of daily living and was unimproved with conservative treatment modalities. She is understanding the risks, benefits, and potential complications as well as all treatment alternatives. The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table. She was given sedative. The thoracodorsal spine was then sterilely prepped and draped in the usual fashion. Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae. Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side. This was directly over the posterior aspect of the pedicle on the left. Once this was localized, the right side was localized as well. Stab incisions were then created over the pedicles of T8 bilaterally. Jamshidi needles were then placed percutaneously. Their position was verified in both AP and lateral images. They were advanced slowly under direct image intensification in biplanar fashion. Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae. The Jamshidi needles were then removed. A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae. This bone was then removed and sent to the lab. The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images. Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle. This was advanced under direct image intensification in a biplanar fashion. Once this was deemed satisfactory, it was impacted. The inner trocar was removed and a guidewire was then placed. An injection cannula was then placed over the guidewire into the body of T7. In a similar fashion, T9 was dressed on the left side as well. A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images. The cement injection cannula was then placed over this entering the T9 vertebrae body. Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae. The balloons were inserted bilaterally. The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg. These were allowed to expand and reduce the fracture. Once this was completed, the balloons were deflated and removed. The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas. This was done directly under image intensification. Once this was completed, additional cement was injected into T9 as there was a larger vertebra. The cement was allowed to cure. The cannula was removed and final radiographs were obtained. The stab incisions were then cleansed with water and antibiotic irrigation. The wounds were then approximated with #4-0 Nylon in interrupted fashion. Compression dressings were applied and fixed with tape. She was aroused and moved to her inpatient bed. She was moving all four extremities without deficit. She had no significant pain.surgery, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,

PREOPERATIVE DIAGNOSIS:, Sterilization candidate.,POSTOPERATIVE DIAGNOSIS:, Sterilization candidate.,PROCEDURE PERFORMED:,1. Cervical dilatation.,2. Laparoscopic bilateral partial salpingectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,Less than 50 cc.,SPECIMEN: , Portions of bilateral fallopian tubes.,INDICATIONS:, This is a 30-year-old female gravida 4, para-3-0-1-3 who desires permanent sterilization.,FINDINGS: , On bimanual exam, the uterus is small, anteverted, and freely mobile. There are no adnexal masses appreciated. On laparoscopic exam, the uterus, bilateral tubes and ovaries appeared normal. The liver margin and bowel 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 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 uterus was then sounded to 7 cm.,The cervix was serially dilated with Hank dilators. A #20 Hank dilator was left in place. The sterile speculum was then removed. Gloves were changed. Attention was then turned to the abdomen where approximately a 10 mm transverse infraumbilical incision was made through the patient's previous scar. The Veress needle was placed and gas was 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 and the camera was placed with the above findings noted. Two 5 mm step trocars were placed, one 2 cm superior to the pubic bone along the midline and the other approximately 7 cm to 8 cm to the left at the level of the umbilicus. The Endoloop was placed through the left-sided port. A grasper was placed in the suprapubic port and put through the Endoloop and then a portion of the left tube was identified and grasped with a grasper. A knuckle of tube was brought up with the grasper and a #0 Vicryl Endoloop synched down across this knuckle of tube. The suture was then cut using the endoscopic shears. The portion of tube that was tied off was removed using a Harmonic scalpel. This was then removed from the abdomen and sent to Pathology. The right tube was then identified and in a similar fashion, the grasper was placed through the loop of the #0 Vicryl Endoloop and the right tube was grasped with the grasper and the knuckle of tube was brought up into the loop. The loop was then synched down. The Endoshears were used to cut the suture. The Harmonic scalpel was then used to remove that portion of tube. The portion of the tube that was removed from the abdomen was sent to Pathology. Both tubes were examined and found to have excellent hemostasis. All instruments were then removed. The 5 mm ports were removed with good hemostasis noted. The camera was removed and the abdomen was allowed to desufflate. The 11 mm trocar introducer was replaced and the trocar was removed. The fascia of the infraumbilical incision was reapproximated with an interrupted suture of #3-0 Vicryl. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. Approximately 10 cc of Marcaine was injected at the incision site. The vulsellum tenaculum and cervical dilator were 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 discharged home with a prescription for Vicodin for pain and was instructed to follow up in the office in two weeks.surgery, cervical dilatation, partial salpingectomy, permanent sterilization, vulsellum tenaculum, hank dilators, infraumbilical incision, vicryl endoloop, salpingectomy, dilatation, hemostasis, cervical, laparoscopic, endoloop, sterilization,

PROCEDURE:, Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years. She comes in this morning with complaints of inability to swallow anything including her saliva. This started almost a day earlier. She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything. She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient. The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed. Daughter was also informed about the procedure and risks. Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg. The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus. There was a meat bolus in the distal esophagus. This was visualized after clearing the liquid material and small particles of what appeared to be carrots. The patient, however, was not tolerating the conscious sedation. Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation. Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net. Then, a snare was used to cut the meat bolus into pieces, as it was very soft. Small pieces were grabbed with the snare and pulled out. Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully. The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy. No active bleeding was seen. There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach. As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction. Treated as described above.,RECOMMENDATIONS:, IV Protonix 40 mg q.12h. Clear liquid diet for 24 hours. If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks. She should take Prevacid SoluTab 30 mg b.i.d. on discharge.surgery, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus,

HISTORY OF PRESENT COMPLAINT: ,Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient landed on her back and hit her head as well. The patient reports sudden, severe left ankle pain and low back pain as well as neck pain in the back of her head. The patient was unable to get up due to severe pain. The patient was afraid that she broke her left ankle. The patient eventually got up and went to her car. The patient went home and symptoms got worse. A few days later, the patient went to the hospital on November 21, 2004. The patient had x-rays of the lumbar spine, left ankle, and left foot. The patient was seen at Healthcare System. She was next seen by Rapid Rehabilitation on December 1, 2004.,nan

HISTORY OF PRESENT ILLNESS:, Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum." Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed. He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife. ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp and vital signs are all within normal limits.,GENERAL: The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES: Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate. It does not protrude beyond the end of the nail plate. There is no active bleeding. There is no edema or erythema of the digit tip. Flexion and extension of the DIP joint is intact. The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off. In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain. Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip. I was able to grasp the splinter and remove this. No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid. If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.consult - history and phy., horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,

CHIEF COMPLAINT:, Joints are hurting all over and checkup.,HISTORY OF PRESENT ILLNESS:, A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema.,She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well.,The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.,PAST MEDICAL HISTORY:, Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.,PAST SURGICAL HISTORY:, She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis.,SOCIAL HISTORY:, The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.,MEDICATIONS:, Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin.,ALLERGIES: , She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,FAMILY HISTORY:, As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment.,REVIEW OF SYSTEMS:,General: No fever, chills, or night sweats. Weight stable.,HEENT: No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions.,Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well.,Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems.,Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years.,GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge.,Musculoskeletal: As above.,Hematological: She has had some anemia in the past.,Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches.,PHYSICAL EXAMINATION:,Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal.,Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present.,Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present.,Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally.,Abdomen: Obese, soft with no hepatosplenomegaly or masses.,Breasts: No predominant masses, discharge, or asymmetry.,Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative.,Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema.,Lymph nodes: No cervical, axillary, or inguinal adenopathy.,Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally.,LABORATORY: ,CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3.,ASSESSMENT:,1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely.,2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear.,3. Diabetes mellitus type II, really fairly well controlled.nan

HISTORY: , The patient is a 71-year-old female, who was referred for an outpatient modified barium swallow study to objectively evaluate her swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals. The patient's complete medical history is unknown to me at this time. The patient was cooperative and compliant throughout this evaluation.,STUDY:, Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. X. The patient was seated upright at a 90-degree angle in a video imaging chair. To evaluate her swallowing function and safety, she was administered graduated amounts of food and liquid mixed with barium in the form of thin liquids (teaspoon x3. cup sip x4); thickened liquid (cup sip x3); puree consistency (teaspoon x3); and solid consistency (1/4 cracker x1). The patient was given 2 additional cup sips of thin liquid following the puree and solid food presentation.,ORAL STAGE: ,The patient had no difficulty with bolus control and transport. No spillage out lips. The patient appears to have pocketing __________ particularly with puree and solid food between her right faucial pillars. The patient did state that she had her tonsil taken out as a child and appears to be a diverticulum located in this state. Further evaluation by an ENT is highly recommended based on the residual and pooling that occurred during this evaluation. We were not able to clear out the residual with alternating cup sips and thin liquid.,PHARYNGEAL STAGE: ,No aspiration or penetration occurred during this evaluation. The patient's hyolaryngeal elevation and anterior movements are within the functional limits. Epiglottic inversion is within functional limits. She had no residual or pooling in the pharynx after the swallow.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: ,The patient had no aspiration or penetration occurred during this evaluation. She does appear to have a diverticulum in the area between her right faucial pillars. Additional evaluation is needed by an ENT physician.,PLAN: ,Based on this evaluation, the following is recommended:,1. The patient's diet should consist regular consistency food with thin liquids. She needs to take small bites and small sips to help decrease her risk of aspiration and penetration as well as reflux.,2. The patient should be referred to an otolaryngologist for further evaluation of her oral cavity particularly the area between her faucial pillars.,The above recommendations and results of the evaluation were discussed with the patient as well as her daughter and both responded appropriately.,Thank you for the opportunity to be required the patient's medical care. She is not in need of skilled speech therapy and is discharged from my services.gastroenterology, globus sensation, oral stage, pharyngeal stage, cervical esophageal stage, consistency, otolaryngologist, barium swallow study evaluation, faucial pillars, swallow study, solid foods, evaluation, liquid, barium, oral, swallow, foods,

ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:, The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:, The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:, The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:, The patient was discharged home.,DISCHARGE INSTRUCTIONS:, His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,

DIAGNOSIS: , Low back pain and degenerative lumbar disk.,HISTORY:, The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.,PAST MEDICAL HISTORY:, Past medical history is significant for allergies and thyroid problems.,PAST SURGICAL HISTORY: , The patient has a past surgical history of appendectomy and hysterectomy.,MEDICATIONS:,1. TriCor.,2. Vytorin.,3. Estradiol.,4. Levothyroxine.,5. The patient is also taking ibuprofen 800 mg occasionally as needed for pain management. The patient states she rarely takes this and does not like to take pain medication if at all possible. The patient states that she has had uncomplicated pregnancies in the past.,SOCIAL HISTORY:, The patient states she lives in a single-level home with her husband, who is in good health and is able to assist with any tasks or activities the patient is having difficulty with. The patient rates her general health as excellent and denies any smoking and reports very occasional alcohol consumption. The patient does state that she has completed exercises on a daily basis of one to one and a half hours a day. However, has not been able to complete these exercise routine since approximately June 2008, secondary to back pain. The patient is working full-time as a project manager, and is required to do extensive walking at various periods during a workday.,MEDICAL IMAGING:, The patient states that she has had an MRI recently performed; however, the results are not available at the time of the evaluation. The patient states she is able to bring the report in upon next visit.,SUBJECTIVE: ,The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.,NEUROLOGICAL SYMPTOMS:, The patient reports having occasional shooting pains into the lower extremities. However, these are occurring less frequently and is now occurring more frequently in the right versus the left lower extremity when they do occur.,FUNCTIONAL ACTIVITIES AND HOBBIES: , Include exercising and general activities.,PATIENT'S GOAL: , The patient would like to improve her overall body movements and return to daily exercise routine as able and well maintaining safety.,OBJECTIVE: , Upon observation, the patient ambulates independently without the use of assistive device. However, does present with mild limp and favoring the left lower extremity after extensive standing and walking activity. The patient does have mild difficulty transferring from the seated position to standing. However, once is upright, the patient denies any increased pain or symptoms.,ACTIVE RANGE OF MOTION OF LUMBAR SPINE: ,Forward flexion is 26 cm, fingertip to floor, lateral side bend, fingertip to floor is 52.5 cm bilaterally.,STRENGTH: , Strength is grossly 4/5. The patient denies any significant tenderness to palpation. However, does have mild increase in tenderness on the right versus left. A six-minute walk test revealed painful symptoms and achiness occurring after approximately 400 feet of walking. The patient was able to continue; however, stopped after 700 feet. There were two minutes remaining in the six-minute walk test. The patient does have tight hamstrings as well as a negative slump test.,ASSESSMENT: , The patient would benefit from skilled physical therapy intervention in order to address the following problem list.,PROBLEM LIST:,1. Increased pain.,2. Decreased ability to complete tasks and hobbies.,3nan

PREOPERATIVE DIAGNOSES: , Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,POSTOPERATIVE DIAGNOSES:, Progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,OPERATIVE PROCEDURE: , Coronary artery bypass grafting (CABG) x4.,GRAFTS PERFORMED: , LIMA to LAD, left radial artery from the aorta to the PDA, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,INDICATIONS FOR PROCEDURE: , The patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina. He had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved LV function. He was advised surgical revascularization of his coronaries.,FINDINGS DURING THE PROCEDURE: ,The aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp. Left internal mammary artery and saphenous vein grafts were good quality conduits. Radial artery graft was a smaller sized conduit, otherwise good quality. All distal targets showed heavy plaque involvement with calcification present. The smallest target was the PDA, which was about 1.5 mm in size. All the other targets were about 2 mm in size or greater. The patient came off cardiopulmonary bypass without any problems. He was transferred on Neo-Synephrine, nitroglycerin, Precedex drips. Cross clamp time was 102 minutes, bypass time was 120 minutes.,DETAILS OF THE PROCEDURE: ,The patient was brought into the operating room and laid supine on the table. After he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right IJ triple-lumen catheter and Cordis catheter, right radial A-line, Foley catheter, TEE probes were placed and interfaced appropriately. The patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion. Preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,After prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed. Left internal mammary artery was taken down. Simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques. Simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques. Subsequent to harvest, the incisions were closed in layers during the course of the procedure.,Heparin was given. Pericardium was opened and suspended. During the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally. Only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,Pericardium was opened and suspended. Pursestring sutures were placed. Aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass. With satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia. An initial dose of about 1500 mL was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,PDA was exposed first. The right coronary artery was calcified along its course all the way to its terminal bifurcation. Even in the PDA, calcification was noted in a spotty fashion. Arteriotomy on the PDA was performed in a soft area and 1.5 probe was noted to be accommodated in both directions. End radial to side PDA anastomosis was constructed using running 7-0 Prolene. Next, the posterolateral obtuse marginal was exposed. Arteriotomy was performed. An end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 Prolene. This graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 Prolene. Next, a slit was made in the left side of the pericardium and LIMA was accommodated in the slit on its way to the LAD. LAD was exposed. Arteriotomy was performed. An end LIMA to side LAD anastomosis was constructed using running 7-0 Prolene. LIMA was tacked down to the epicardium securely utilizing its fascial pedicle.,Two stab incisions were made in the ascending aorta and enlarged using 4-mm punch. Two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 Prolene. The patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed. Following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity. Temporary V-pacing wires were placed. Blake drains were placed in the left chest, the right chest, as well as in the mediastinum. Left chest Blake drain was placed just in the medial section where dissection had been performed. After an adequate period of rewarming during which time, temporary V-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems. With satisfactory hemodynamics, good LV function on TEE and baseline EKG, heparin was reversed using protamine. Decannulation was performed after volume resuscitation. Hemostasis was assured. Mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy Vicryl for musculofascial closure, and Monocryl for subcuticular skin closure. Dressings were applied. The patient was transferred to the ICU in stable condition. He tolerated the procedure well. All counts were correct at the termination of the procedure. Cross clamp time was 102 minutes. Bypass time was 120 minutes. The patient was transferred on Neo-Synephrine, nitroglycerin, and Precedex drips.cardiovascular / pulmonary, radial artery, lima, pda, obtuse marginal, exertional angina, coronary artery disease, triple-vessel, graft, conduit, ij triple-lumen catheter, cordis catheter, a-line, foley catheter, tee probes, coronary artery bypass grafting, cross clamp, mammary artery, saphenous vein, coronary artery, artery, cabg, coronary, grafting, aorta, angina, bypass

PREOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1. Metatarsus primus varus with bunion deformity, right foot.,2. Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1. Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2. Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems. The foot problem has been progressive in nature and has not been responsive to conservative treatment. The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail. The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain. All questions were thoroughly answered. The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities. The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE: ,The patient was brought to the operating room and placed in a supine position. No tourniquet was utilized. IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. The lower extremity was prepped and draped in the usual sterile manner. Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot. A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx. Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized. A linear periosteal capsular incision was made in line with the skin incision. The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface. Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head. The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition. The sesamoid was in satisfactory condition. An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration. Care was taken to preserve the sagittal groove. The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment. The access guide was noted to be in good position. A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed. The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal. The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head. The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment. It was then fixated with 1 screw. A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction. The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position. Compression and fixation were noted to be satisfactory. Inspection revealed good fixation and alignment at the operative site. Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally. All rough edges were rasped smooth. Examination revealed there was still lateral deviation of the hallux. A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:, Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux. The original skin incision was extended from the point just distal to the interphalangeal joint. All vital structures were identified and retracted. Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface. The focus of the deformity was noted to be more distal on the hallux. Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected. The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site. The alignment and contour of the first way was now satisfactorily improved. The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation. The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl. The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia. A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression. The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied. The patient should wear it when walking or standing., ,The next office visit will be in 4 days. The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions. The patient was discharged home with vital signs stable in no acute distress.

PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.neurosurgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,

DIAGNOSES:,1. Disseminated intravascular coagulation.,2. Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.,PAST MEDICAL HISTORY: ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY: ,There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY: ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL: She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS: She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT: Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place.,NECK: No jugular venous pressure distention.,CHEST: Coarse breath sounds bilaterally.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line.,EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES: ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN: ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.hematology - oncology, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,

PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma (0.8 cm diameter), right medial canthus.,OPERATION: , Excision basal cell carcinoma (0.8 cm diameter), right medial canthus with frozen section, and reconstruction of defect (1.2 cm diameter) with glabellar rotation flap.,ANESTHESIA:, Monitored anesthesia care.,JUSTIFICATION: , The patient is an 80-year-old white female with a biopsy-proven basal cell carcinoma of the right medial canthus. She was scheduled for elective excision with frozen section under local anesthesia as an outpatient.,PROCEDURE: , With an intravenous infusing and under suitable premedication, the patient was placed supine on the operative table. The face was prepped with pHisoHex draped. The right medial canthal region and the glabellar region were anesthetized with 1% Xylocaine with 1:100,000 epinephrine.,Under loupe magnification, the lesion was excised with 2 mm margins, oriented with sutures and submitted for frozen section pathology. The report was "basal cell carcinoma with all margins free of tumor." Hemostasis was controlled with the Bovie. Excised lesion diameter was 1.2 cm. The defect was closed by elevating a left laterally based rotation flap utilizing the glabellar skin. The flap was elevated with a scalpel and Bovie, rotated into the defect without tension, ***** to the defect with scissors and inset in layer with interrupted 5-0 Vicryl for the dermis and running 5-0 Prolene for the skin. Donor site was closed in V-Y fashion with similar suture technique.,The wounds were dressed with bacitracin ointment. The patient was returned to the recovery room in satisfactory condition. She tolerated the procedure satisfactorily, and then no complications. Blood loss was essentially nil.surgery, basal cell carcinoma, excision, bacitracin, canthal region, canthus, frozen section, glabellar, glabellar region, loupe magnification, phisohex, rotation flap, loupe, excision basal cell carcinoma, medial canthus, basal cell, cell carcinoma, basal, cell, carcinoma,

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation. The original consultation and treatment planning will be separately performed. At the time of the implantation, special coordination will be required. Stepping ultrasound will be performed and utilized in the pre-planning process. Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. Modifications will be made in real time to add or subtract needles and seeds as required. This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate. Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.urology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: 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 DIAGNOSES:, Left calcaneal valgus split.,POSTOPERATIVE DIAGNOSES:, Left calcaneal valgus split.,PROCEDURES: ,1. Left calcaneal lengthening osteotomy with allograft.,2. Partial plantar fasciotomy.,3. Posterior subtalar and tibiotalar capsulotomy.,4. Short leg cast placed.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME: , 69 minutes.,The patient in local anesthetic of 20 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: ,None.,SPECIMENS: , None.,HISTORY AND PHYSICAL: , The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age. Since that time, the patient has developed significant calcaneal valgus deformity with significant pain. Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot. Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening. Risks and benefits of surgery were discussed with the mother. Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months. All questions were answered and parents agreed to the above surgical plan.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient received Ancef preoperatively. A bump was placed underneath the left buttock. A nonsterile tourniquet was placed on the upper aspect of the left thigh. The extremity was then prepped and draped in a standard surgical fashion. The patient had a previous incision along the calcaneocuboid lateral part of the foot. This was marked and extended proximally through the Achilles tendon. Extremity was wrapped in Esmarch. Tourniquet inflation was noted to be 250 mmHg. Decision was then made to protect the sural nerve. There was one sensory nervous branch that did cross the field though it was subsequently sharply ligated because it was in the way. Dissection was carried down to Achilles tendon, which was subsequently de-lengthened with the distal half performed down the lateral thigh. Proximal end was tacked with an 0 Ethibond suture and subsequently repaired end-on-end at length with the heel in neutral. Dissection was then carried on the lateral border of the foot with identification of the peroneal longus and valgus tendons, which were removed from the sheath and retracted dorsally. At this time, we also noted that calcaneocuboid joint appeared to be fused. The area between the anterior and middle facets were plicated on fluoroscopy for planned osteotomy. This was performed with a saw. After a partial plantar fasciotomy was performed, this was released off an abductor digiti minimi. The osteotomy was completed with an osteotome and distracted with the lamina spreader. A tricortical allograft was then shaped and subsequently impacted into this area. Final positioning was checked with multiple views of fluoroscopy. It was subsequently fixed using a 0.94 K-wire and drilled from the heel anteriorly. A pin was subsequently bent and cut short at the level of the skin. The wound was then irrigated with normal saline. The Achilles was repaired with this tie. Please note during the case, it was noted the patient had continued significant stiffness despite the Achilles lengthening. A posterior capsulotomy of the tibiotalar and subtalar joints were performed with increased 10 degrees of dorsiflexion. Wound was then closed using #2-0 Vicryl and #4-0 Monocryl. The surgical field was irrigated with 0.25% Marcaine and subsequently injected with more Marcaine at the end of the case. The wound was clean and dry and dressed with Steri-Strips and Xeroform. Skin was dressed with Xeroform and 4 x 4's. Everything was wrapped with 4 x 4's in sterile Webril. The tourniquet was released after 69 minutes. A short-leg cast was then placed with good return of capillary refill to his toes. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for elevation, ice packs, neurovascular checks, and pain control. The patient to be strict nonweightbearing. We will arrange for her to get a wheelchair. The patient will then follow up in about 10 to 14 days for a cast check, as well as pain control. The patient will need an AFO script at that time. Intraoperative findings are relayed to the parents.orthopedic, calcaneal lengthening, osteotomy, allograft, plantar fasciotomy, capsulotomy, calcaneal valgus split, partial plantar fasciotomy, short leg cast, achilles lengthening, calcaneal valgus, tourniquet, plantar, valgus, achilles, calcaneal,

DIAGNOSES:,1. Juvenile myoclonic epilepsy.,2. Recent generalized tonic-clonic seizure.,MEDICATIONS:,1. Lamictal 250 mg b.i.d.,2. Depo-Provera.,INTERIM HISTORY: , The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal. Pupils are equal and reactive to light. Extraocular movements are intact. There is no nystagmus. Visual fields are full. Demeanor is normal. Facial sensation and symmetry is normal. No myoclonic jerks noted during this examination. No myoclonic jerks provoked by tapping on her upper extremity muscles. Negative orbit. Deep tendon reflexes are 2 and symmetric. Gait is normal. Tandem gait is normal. Romberg negative.,IMPRESSION AND PLAN:, Recurrence of early morning myoclonus despite high levels of Lamictal. She is tolerating the medication well and has not had a generalized tonic-clonic seizure. She is concerned that this is a precursor for another generalized seizure. She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra. This was thought secondary to severe insomnia when her baby was very young. Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d. Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.neurology, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure

PREOPERATIVE DIAGNOSES:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,POSTOPERATIVE DIAGNOSIS:,1. Pregnancy at 40 weeks.,2. Failure to progress.,3. Premature prolonged rupture of membranes.,4. Group B strep colonization.,5. Delivery of viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cesarean section via Pfannenstiel incision.,ANESTHESIA: ,Spinal.,ESTIMATED BLOOD LOSS: , 1000 cc.,FLUID REPLACEMENT: , 2700 cc crystalloid.,URINE:, 500 cc clear yellow urine in the Foley catheter.,INTRAOPERATIVE FINDINGS: ,Normal appearing uterus, tubes, and ovaries. A viable male neonate with Apgars of 9 and 9 at 1 and 5 minutes respectively. Infant weight equaled to 4140 gm with clear amniotic fluid. The umbilical cord was wrapped around the leg tightly x1. Infant was in a vertex, right occiput anterior position.,INDICATIONS FOR PROCEDURE: ,The patient is a 19-year-old G1 P0 at 41 and 1/7th weeks' intrauterine pregnancy. She presented at mid night on 08/22/03 complaining of spontaneous rupture of membranes, which was confirmed in Labor and Delivery. The patient had a positive group beta strep colonization culture and was started on penicillin. The patient was also started on Pitocin protocol at that time. The patient was monitored throughout the morning showing some irregular contractions every 5 to 6 minutes and then eventually no contractions on the monitor. IUPC was placed without difficulty and contractions appeared to be regular, however, they were inadequate amount of the daily units. The patient was given a rest from the Pitocin. She walked and had a short shower. The patient was then placed back on Pitocin with IUPC in place and we were unable to achieve adequate contractions. Maximum cervical dilation was 5 cm, 80% effaced, negative 2 station, and cephalic position. At the time of C-section, the patient had been ruptured for over 24 hours and it was determined that she would not progress in her cervical dilation, as there was suspected macrosomia on ultrasound. Options were discussed with the patient and family and it was determined that we will take her for C-section today. Consent was signed. All questions were answered with Dr. X present.,PROCEDURE: , The patient was taken to the operative suite where a spinal anesthetic was placed. She was placed in the dorsal supine position with left upward tilt. She was prepped and draped in the normal sterile fashion and her spinal anesthetic was found to adequate. A Pfannenstiel incision was made with a first scalpel and carried through the underlying layer of fascia with a second scalpel. The fascia was incised in the midline and extended laterally using curved Mayo scissors. The superior aspect of the fascial incision was grasped with Ochsner and Kocher clamps and elevated off the rectus muscles. Attention was then turned to the inferior aspect of the incision where Kocher clamps were used to elevate the fascia off the underlying rectus muscle. The rectus muscle was separated in the midline bluntly. The underlying peritoneum was tented up with Allis clamps and incised using Metzenbaum scissors. The peritoneum was then bluntly stretched. The bladder blade was placed. The vesicouterine peritoneum was identified, tented up with Allis' and entered sharply with Metzenbaum scissors. The incision was extended laterally and the bladder flap created digitally. The bladder blade was then reinserted in the lower uterine segment. A low transverse uterine incision was made with a second scalpel. The uterine incision was extended laterally bluntly. The bladder blade was removed and the infant's head was delivered with the assistance of a vacuum. Infant's nose and mouth were bulb suctioned and the body was delivered atraumatically. There was, of note, an umbilical cord around the leg tightly x1.,Cord was clamped and cut. Infant was handed to the waiting pediatrician. Cord gas was sent for pH as well as blood typing. The placenta was manually removed and the uterus was exteriorized and cleared of all clots and debris. The uterine incision was grasped circumferentially with Alfred clamps and closed with #0-Chromic in a running locked fashion. A second layer of imbricating stitch was performed using #0-Chromic suture to obtain excellent hemostasis. The uterus was returned to the abdomen. The gutters were cleared of all clots and debris. The rectus muscle was loosely approximated with #0-Vicryl suture in a single interrupted fashion. The fascia was reapproximated with #0-Vicryl suture in a running fashion. The subcutaneous Scarpa's fascia was then closed with #2-0 plain gut. The skin was then closed with staples. The incision was dressed with sterile dressing and bandage. Blood clots were evacuated from the vagina. The patient tolerated the procedure well. The sponge, lap, and needle counts were correct x2. The mother was taken to the recovery room in stable and satisfactory condition.surgery, c-section, cesarean section, low transverse, pregnancy, rupture of membranes, cervical dilation, kocher clamps, metzenbaum scissors, vicryl suture, pfannenstiel incision, uterine incision, rectus muscles, incision, transverse, colonization, rectus, muscles, bladder, uterine, section, fascia,

MALE PHYSICAL EXAMINATION,Eye: Eyelids normal color, no edema. Conjunctivae with no erythema, foreign body, or lacerations. Sclerae normal white color, no jaundice. Cornea clear without lesions. Pupils equally responsive to light. Iris normal color, no lesions. Anterior chamber clear. Lacrimal ducts normal. Fundi clear.,Ear: External ear has no erythema, edema, or lesions. Ear canal unobstructed without edema, discharge, or lesions. Tympanic membranes clear with normal light reflex. No middle ear effusions.,Nose: External nose symmetrical. No skin lesions. Nares open and free of lesions. Turbinates normal color, size and shape. Mucus clear. No internal lesions.,Throat: No erythema or exudates. Buccal mucosa clear. Lips normal color without lesions. Tongue normal shape and color without lesion. Hard and soft palate normal color without lesions. Teeth show no remarkable features. No adenopathy. Tonsils normal shape and size. Uvula normal shape and color.,Neck: Skin has no lesions. Neck symmetrical. No adenopathy, thyromegaly, or masses. Normal range of motion, nontender. Trachea midline.,Chest: Symmetrical. Clear to auscultation bilaterally. No wheezing, rales or rhonchi. Chest nontender. Normal lung excursion. No accessory muscle use.,Cardiovascular: Heart has regular rate and rhythm with no S3 or S4. Heart rate is normal.,Abdominal: Soft, nontender, nondistended, bowel sounds present. No hepatomegaly, splenomegaly, masses, or bruits.,Genital: Penis normal shape without lesions. Testicles normal shape and contour without tenderness. Epididymides normal shape and contour without tenderness. Rectum normal tone to sphincter. Prostate normal shape and contour without nodules. Stool hemoccult negative. No external hemorrhoids. No skin lesions.,Musculoskeletal: Normal strength all muscle groups. Normal range of motion all joints. No joint effusions. Joints normal shape and contour. No muscle masses.,Foot: No erythema. No edema. Normal range of motion all joints in the foot. Nontender. No pain with inversion, eversion, plantar or dorsiflexion.,Ankle: Anterior and posterior drawer test negative. No pain with inversion, eversion, dorsiflexion, or plantar flexion. Collateral ligaments intact. No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee: Normal range of motion. No joint effusion, erythema, nontender. Anterior and posterior drawer tests negative. Lachman's test negative. Collateral ligaments intact. Bursas nontender without edema.,Wrist: Normal range of motion. No edema or effusion, nontender. Negative Tinel and Phalen tests. Normal strength all muscle groups.,Elbow: Normal range of motion. No joint effusion or erythema. Normal strength all muscle groups. Nontender. Olecranon bursa flat and nontender, no edema. Normal supination and pronation of forearm. No crepitus.,Hip: Negative swinging test. Trochanteric bursa nontender. Normal range of motion. Normal strength all muscle groups. No pain with eversion and inversion. No crepitus. Normal gait.,Psychiatric: Alert and oriented times four. No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality. Affect is appropriate. No psychomotor slowing or agitation. Eye contact is appropriate.general medicine, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia. The patient ruled out for myocardial infarction with serial troponins. Nuclear stress test has been done, results of which are pending. The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks. Discharge medications will depend on results of nuclear stress test.office notes, chest pain, serial troponins, premature coronary artery disease, coronary artery disease, nuclear stress test, stress test

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.discharge summary, emesis, cough, upper respiratory illness, respiratory illness, apnea, pertussis,

INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit. The patient is appropriately immobilized using a customized immobilization device. Preliminary simulation films are obtained and approved by me. The patient is marked and transferred to the CT scanner. Sequential images are obtained and transferred electronically to the treatment planning software. Extensive analysis then occurs. The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition organs at risk are outlined. Appropriate doses are selected, both for the target, as well as constraints for organs at risk. Inverse treatment planning is performed by the physics staff under my supervision. These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.radiology, target volume, intensity modulated radiation therapy, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

PROCEDURE DONE: ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:, Chest pain.,PROCEDURE:, 13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained. Pharmacologic stress testing was done using adenosine infusion. Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes. Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected. Resting heart rate was 90 beats per minute. Resting blood pressure was 130/70. Peak heart rate obtained during adenosine infusion was 102 beats per minute. Blood pressure obtained during adenosine infusion was 112/70. During adenosine infusion, patient experienced dizziness and shortness of breath. No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect. Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium. Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%. Lung heart ratio was 0.40. TID ratio was 0.88.,IMPRESSION:, Normal adenosine Myoview myocardial perfusion SPECT. Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.radiology, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,

PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA: ,Topical.,PROCEDURE IN DETAIL: ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite. Hemodynamic monitoring was begun. Time-out was called and the patient eye operated upon and lens implant intended were verbally verified. Three drops of tetracaine were applied to the operative eye. The patient was then prepped and draped in usual sterile fashion for intraocular surgery. A lid speculum was placed. Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife. The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat. The clear corneal temporal incision was fashioned. The anterior chamber was entered by introducing a keratome. The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps. The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique. Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally. This area was tamponaded with Healon. The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse. An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area. The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus. There was noted to be good support. Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat. Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly. The pupil was noted to constrict symmetrically. Wounds were checked with Weck-cels and found to be free of vitreous. BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12. All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous. A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried. Lid speculum was removed. TobraDex ointment, light patch and a Soft Shield were applied. The patient was taken to the recovery room, awake and comfortable. We will follow up in the morning for postoperative check. He will not be given Diamox due to his sulfa allergy. The intraoperative course was discussed with both he and his wife.surgery, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,

PREOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,POSTOPERATIVE DIAGNOSIS: , Symptomatic cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy and appendectomy (CPT 47563, 44970).,ANESTHESIA: , General endotracheal.,INDICATIONS: ,This is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis. She requested appendectomy because of the concern of future diagnostic dilemma with pain crisis. Laparoscopic cholecystectomy and appendectomy were recommended to her. The procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones. After answering her questions, she wished to proceed and gave informed consent.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. She was positively identified and the correct surgical site and procedure reviewed. After successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,The infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created. The linea alba was grasped with a hemostat and Veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmHg. A 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity. Upper abdominal anatomy was normal. Pelvic laparoscopy revealed bilaterally closed internal inguinal rings. Additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____. There was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region. Using these, the gallbladder was grasped and retraced cephalad. Adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction. A small ductotomy was created. Reddick cholangiogram catheter was then placed within the duct and the balloon inflated. Continuous fluoroscopy was used to instill contrast material. This showed normal common bile duct which entered the duodenum without obstruction. There was no evidence of common bile duct stones. The cholangiogram catheter was removed. The duct was doubly clipped and divided. The artery was divided and cauterized. The gallbladder was taken out of the gallbladder fossa. It was then placed in Endocatch bag and left in the abdomen. Attention was then paid to the appendix. The appendix was identified and window was made in the mesoappendix at the base. This was amputated with an Endo-GIA stapler. The mesoappendix was divided with an Endo-GIA vascular stapler. This was placed in another Endocatch bag. The abdomen was then irrigated. Hemostasis was satisfactory. Both the appendix and gallbladder were removed and sent for pathology. All trocars were removed. The 12-mm port sites were closed with 2-0 PDS figure-of-eight fascial sutures. The umbilical skin was reapproximated with interrupted 5-0 Vicryl Rapide. The remaining skin incisions were closed with 5-0 Monocryl subcuticular suture. The skin was cleaned. Mastisol, Steri-Strips and band-aids were applied. The patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.surgery, endo-gia, endocatch bag, symptomatic cholelithiasis, laparoscopic cholecystectomy, appendectomy, cholangiogram, mesoappendix, abdomen, appendix, cholelithiasis, endotracheal, laparoscopic, cholecystectomy, gallbladder, duct

CHIEF COMPLAINT:, Well-child check sports physical.,HISTORY OF PRESENT ILLNESS:, This is a 14-1/2-year-old white male known to have asthma and allergic rhinitis. He is here with his mother for a well-child check. Mother states he has been doing well with regard to his asthma and allergies. He is currently on immunotherapy and also takes Advair 500/50 mg, Flonase, Claritin and albuterol inhaler as needed. His last exacerbation was 04/04. He has been very competitive in his sports this spring and summer and has had no issues since that time. He eats well from all food groups. He has very good calcium intake. He will be attending Maize High School in the ninth grade. He has same-sex and opposite-sex friends. He has had a girlfriend in the past. He denies any sexual activity. No use of alcohol, cigarettes or other drugs. His bowel movements are without problems. His immunizations are up to date. His last tetanus booster was in 07/03.,CURRENT MEDICATIONS:, As above.,ALLERGIES: , He has no known medication allergies.,REVIEW OF SYSTEMS:,Constitutional: He has had no fever.,HEENT: No vision problems. No eye redness, itching or drainage. No earache. No sore throat or congestion.,Cardiovascular: No chest pain.,Respiratory: No cough, shortness of breath or wheezing.,GI: No stomachache, vomiting or diarrhea.,GU: No dysuria, urgency or frequency.,Hematological: No excessive bruising or bleeding. He did have a minor concussion in 06/04 while playing baseball.,PHYSICAL EXAMINATION:,General: He is alert and in no distress.,Vital signs: He is afebrile. His weight is at the 75th percentile. His height is about the 80th percentile.,HEENT: Normocephalic. Atraumatic. Pupils are equal, round and reactive to light. TMs are clear bilaterally. Nares patent. Nasal mucosa is mildly edematous and pink. No secretions. Oropharynx is clear.,Neck: Supple.,Lungs: Good air exchange bilaterally.,Heart: Regular. No murmur.,Abdomen: Soft. Positive bowel sounds. No masses. No hepatosplenomegaly.,GU: Male. Testes descended bilaterally. Tanner IV. No hernia appreciated.,Extremities: Symmetrical. Femoral pulses 2+ bilaterally. Full range of motion of all extremities.,Back: No scoliosis.,Neurological: Grossly intact.,Skin: Normal turgor. Minor sunburn on upper back.,Neurological: Grossly intact.,ASSESSMENT:,1. Well child.,2. Asthma with good control.,3. Allergic rhinitis, stable.,PLAN:, Hearing and vision assessment today are both within normal limits. Will check an H&H today. Continue all medications as directed. Prescription written for albuterol inhaler, #2, one for home and one for school to be used for rescue. Anticipatory guidance for age. He is to return to the office in one year or sooner if needed.nan

REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:, The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested. The patient denies any chest pain or shortness of breath. Chest x-ray and CAT scan shows possible pneumonia. The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:, At this time, he is on:,1. Atrovent and albuterol nebulizers.,2. Azithromycin.,3. Potassium chloride 10 mEq p.o. daily.,4. Furosemide 20 mg IV daily.,5. Enoxaparin 40 mg daily.,6. Lisinopril 10 mg p.o. daily.,7. Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:, History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke. Drinks occasionally.,FAMILY HISTORY: ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea. He has cough. No fever. No abdominal pain. No syncope, near-syncope, or palpitation. All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL: The patient is comfortable, not in distress.,VITAL SIGNS: His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT: Atraumatic, normocephalic. Eyes PERRLA.,NECK: Supple. No JVD. No carotid bruit.,CHEST: Clear.,HEART: S1 and S2, regular. No S3. No S4. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds.,EXTREMITIES: No cyanosis, clubbing, or edema. Pulse 2+.,CNS: Alert, awake, and oriented x3.,DIAGNOSTIC DATA:, EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay. CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. Loculated pleural effusion in the left upper lobe. No PE. Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05. White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1. Pneumonia.,2. Diastolic heart failure, not contributing to his present problem.,3. Hypertension, controlled.,4. History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics. No further cardiac workup at this time.nan

PROCEDURES:,1. Esophagogastroduodenoscopy.,2. Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1. History of esophageal cancer.,2. History of colonic polyps.,POSTOPERATIVE FINDINGS:,1. Intact surgical intervention for a history of esophageal cancer.,2. Melanosis coli.,3. Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:, Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:, The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:, The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation. The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1. ESOPHAGUS: Anatomy consistent with esophagectomy with colonic transposition.,2. STOMACH: Revealed colonic transposition with normal mucosa.,3. DUODENUM: Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice. Circumferential visualization the colonic mucosa revealed the following:,1. Cecum revealed melanosis coli.,2. Ascending, melanosis coli.,3. Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4. Descending, melanosis coli.,5. Sigmoid, melanosis coli.,6. Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology. Continue fiber with avoidance of stimulant laxatives.nan

REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.,IMPRESSION:,1. Concentric hypertrophy of the left ventricle with left ventricular function.,2. Moderate mitral regurgitation.,3. Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.radiology, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic

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

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

DESCRIPTION OF OPERATION:, The patient was brought to the operating room and appropriately identified. Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block. The patient was prepped and draped in the usual sterile fashion. A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants. Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. The MVR blade was used to make a sclerotomy between the pre-placed sutures. An 8-0 nylon suture was then pre-placed for later sclerotomy closure. The infusion cannula was inspected and found to be in good working order. The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures. The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants. The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed. There was moderately severe vitreous hemorrhage, which was removed. Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades. These were dissected with curved scissors and judicious use of the vitrectomy cutter. There was some bleeding from the inferotemporal frond. This was managed by raising the intraocular pressure and using intraocular cautery. The surgical view became cloudy and the corneal epithelium was removed with a beaver blade. This improved the view. There is an area suspicious for retinal break near where the severe traction was inferotemporally. The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment. The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen. There was some residual hemorrhagic vitreous skirt seen. The soft-tip cannula was then used to perform an air-fluid exchange. Additional laser was placed around the suspicious area inferotemporally. The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut. A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye. The lid speculum was removed. Maxitrol ointment was instilled over the eye and the eye was patched. The patient was brought to the recovery room in stable condition.ophthalmology, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE

IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested.sleep medicine, sleep, vertex activity, muscle artifact, sharp wave activity, electroencephalogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extremity was then prepped and draped in the usual manner. A sterile tourniquet was placed on the proximal aspect of the right upper extremity. The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg. Tourniquet time was 74 minutes. A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. Hemostasis was achieved utilizing electrocautery. Subcutaneous fat was separated and the skin flaps elevated. The _________ was identified. It was incised. The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. There was some serosanguineous fluid from the previous rupture. This area was suctioned clean. The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. At this point, the #2 fiber wire was then passed through the tendon. Two fiber wires were utilized in a Krackow-type suture. Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. The radial tuberosity was palpated. Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. A skin incision was made over this area. Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa. The tails of the fiber wire suture were grasped and pulled down through the second incision. At this point, they were placed to the side. Attention was directed at exposure of the radial tuberosity with a forearm fully pronated. The tuberosity came into view. The margins were cleared with periosteal elevator and sharp dissection. Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. Three small drill holes were then placed along the margin for passage of the suture. The area was then copiously irrigated with gentamicin solution. A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. The suture was tied over the bone islands. Both wounds were then copiously irrigated with gentamicin solution and suctioned dry. Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples. The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples. Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia. A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. Tourniquet was inflated prior to application of the splint. Circulatory status returned to the extremity immediately. The patient was awakened. He was rather boisterous during his awakening, but care was taken to protect the right upper extremity. He was then transferred to the recovery room in apparent satisfactory condition.orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint. The patient complains of fatigue, nausea, vomiting and fever. The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement. The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked. The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem. At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed. As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work". The patient has had dialysis since January secondary to hypertension-induced renal failure. He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center. He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago. The patient's history at this point is a little sketchy; however, he states that he left AMA. All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years. No alcohol, occasional marijuana, and no IV drug use. He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs: In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air. General: This is an alert and oriented African-American male x3 and in no acute distress. The patient is extremely lethargic and had to be aroused multiple times to answer questions. Mucous membranes are moist. HEENT: Head is normocephalic and atraumatic. There is no scleral icterus noted. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Cardiovascular: Shows a heart rate that is regular with a laterally displaced point of maximum intensity. There is no murmur, gallop, or rub noted. Lungs: Clear to auscultation bilaterally. No wheeze, rhonchi or rales. Abdomen: Soft, nontender and nondistended. Bowel sounds are present. Extremities: Show left forearm with an incision that is well healed from a left AV fistula. There is a distal thrill palpable and there is some tenderness over the incisional area. There is no erythema or pus noted. Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131. Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1. Nonfunctional AV fistula.,2. End-stage renal disease.,3. Hypertension.,4. Status post MI.,5. Clogged PermCath.,PLAN:,1. Give the patient TPA to the shunt, PermCath in both feet.,2. To board for Tuesday for shunt repair if needed.,3. To dialyze as soon as possible.,4. To review previous operative report.,5. The patient will be contacted in the morning and told whether to go to dialysis or not.nan

CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS: ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full.,NECK: Supple with full range of motion and no masses.,LUNGS: There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN: Soft and nontender with no hepatosplenomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole.,3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium.,4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. ,

PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:, Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA: ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:, 10 mL.,FLUIDS:, 1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition. Breathing spontaneously.,INDICATION FOR PROCEDURE: ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible. Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table. As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics. The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion. After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx. Peridex mouth rinse was used to prep the oral cavity. This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus. A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier. Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces. Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture. The throat pack was removed. The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition.dentistry, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible,

SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. General: The patient is nontoxic and in no acute distress. Musculoskeletal: The right hand was examined. It appears to be within normal limits and the appearance is similar to the left hand. She has good and equal grip strength noted bilaterally. She has negative Tinel's bilaterally. She has a positive Phalen's test. The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT: ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. I suspect carpal tunnel syndrome.,PLAN: ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time. She is going to let me know. While she is here, I am going to also get her the blood test she needs for her diabetes. I am noting that her blood pressure is elevated, but improved from the last visit. I also noticed that she has lost a lot of weight. She is working on diet and exercise and she is doing a great job. Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling

REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme. She presented with several lesions in her brain and a biopsy confirmed the diagnosis. She was seen by Dr. X in our group. Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department. Details of her treatment are not available at the time of this dictation. Her family has a packet of Temodar 100-mg pills. She is admitted now with increasing confusion. A CT shows increase in size of the lesions compared to the preoperative scan. We are asked to comment on her treatment at this point. She herself is confused and is unable to provide further history. ,PAST MEDICAL HISTORY: , From her old chart: No known past medical history prior to the diagnosis.,SOCIAL HISTORY: ,She was living alone and is now living in assisted living. ,MEDICATIONS,1. Dilantin 300 mg daily.,2. Haloperidol 1 mg h.s.,3. Dexamethasone 4 mg q.i.d. ,4. Docusate 100 mg b.i.d.,5. Pen-VK 500 mg daily.,6. Ibuprofen 600 mg daily.,7. Zantac 150 mg twice a day.,8. Temodar 100 mg daily.,9. Magic Mouthwash daily.,10. Tylenol #3 as needed.,REVIEW OF SYSTEMS,: Unable.,PHYSICAL EXAMINATION,GENERAL: Elderly woman, confused. ,HEENT: Normal conjunctivae. Ears and nose normal. Mouth normal.,NECK: Supple.,CHEST: Clear.,HEART: Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC: Alert, cranial nerves intact. Left arm slightly weak. Left leg slightly weak.,IMPRESSION AND PLAN:, Glioblastoma multiforme, uncertain as to where she is in cancer treatment. Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor. We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen. At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.nan

INTERPRETATION:,1. Predominant rhythm is normal sinus rhythm.,2. No supraventricular arrhythmia.,3. Frequent premature ventricular contractions.,4. Trigemini and couplets.,5. No high-grade atrial ventricular block was noted.,6. Diary was not kept.,IMPRESSION:, Frequent premature atrial contractions, couplets, and trigemini.,cardiovascular / pulmonary, atrial ventricular block, holter monitor report, holter monitor, frequent premature, holter, monitor, rhythm, ventricular, contractions, trigemini, atrial,

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:, LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones. The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion. A 0.035 glidewire was placed in the left system. Using graspers, left-sided stent was removed. A semirigid ureteroscopy was done. A stone was visualized in the mid to upper ureter. Using laser, the stone was broken into 5 to 6 small pieces. Using basket extraction, all the pieces were removed. Ureteroscopy all the way up to the UPJ was done, which was negative. There were no further stones. Using pyelograms, the rest of the system appeared normal. The entire ureter on the left side was open and patent. There were no further stones. Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. Over the 0.035 glidewire, a 26 double-J stent was placed. There was a nice curl in the kidney and one in the bladder. The patient tolerated the procedure well. Please note that the string was kept in place and the patient was to remove the stent the next day. The patient's family was instructed how to do so. The patient had antibiotics and pain medications at home. The patient was brought to recovery room in a stable condition.surgery, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,

EXAM:,MRI OF THE LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain. Twisting injury.,FINDINGS:,The images reveal a sizable joint effusion. The joint effusion appears to be complex with mixed signal intensity material within. The patella is slightly laterally tilted towards the left. The mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. Mildly increased bone signal overlying the inferolateral portion of the patella is identified. No significant degenerative changes about the patella can be seen. The quadriceps tendon as well as the infrapatellar ligament both look intact. There is some prepatellar soft tissue edema.,The bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. NO significant areas of bone edema are appreciated.,There is soft tissue edema along the lateral aspect of the knee. There is a partial tear of the lateral collateral ligament complex. The medial collateral ligament complex looks intact. A small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,The posterior cruciate ligament looks intact. The anterior cruciate ligament is thickened with significant increased signal. I suspect at least a high grade partial tear.,The posterior horn of the medial meniscus shows some myxoid degenerative changes. The posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. I don’t see a definite tear extending to the articular surface.,IMPRESSION:,Sizeable joint effusion which is complex and may contain blood products.,Myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,Soft tissue swelling and partial tear of the lateral collateral ligament complex.,At least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,The posterior cruciate ligament is intact.,Injury to the patellar cartilage as above.radiology, lateral collateral ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, collateral ligament complex, myxoid degenerative, partial tear, collateral ligament, ligament complex, cruciate ligament, mri, effusion, cartilage, collateral, cruciate, knee, tear, ligament

CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray. He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion. Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock. A ring block was also done using another 0.3 mL of lidocaine. Glucose water is also used for anesthesia. After several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus. The blunt probe was then introduced again with care taken to avoid the meatus. After initial adhesions were taken down the straight clamp was introduced to break down further adhesions. Care was taken to avoid the frenulum. The clamps where then repositioned at 12 and 6 o'clock. The Mogen clamp was then applied with a dorsal tilt. After the clamp was applied for 1 minute the foreskin was trimmed. After an additional minute the clamp was removed and the final adhesions were taken down. Patient tolerated the procedure well with minimal bleeding noted. Patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,Routine care discussed with the family. Need to clean the area with just water initially and later with soap and water or diaper wipes once healed.urology, circumcision, 1% lidocaine, betadine, glucose water, adhesions, circumcision tray, diaper wipes, foreskin, frenulum, meatus, straight clamp, sterile fashion, clampNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of "dystonia.",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild "ataxia" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal,

PREOPERATIVE DIAGNOSES:,1. Nasopharyngeal mass.,2. Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1. Nasopharyngeal tube mass.,2. Right upper lid skin lesion.,PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Excision of nasopharyngeal mass via endoscopic technique.,3. Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan. The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. It appears to be growing in size and is irregularly bordered. After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position. After this, the patient was turned to 90 degrees by the Department of Anesthesia. The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade. After this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors. After this, the ________ was then hemostatically controlled with monopolar cauterization. The patient's skin was then reapproximated with a running #6-0 Prolene suture. A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment. Attention then was drawn to the nasopharynx. The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. The patient had a severely deviated nasal septum more so to the right than the left. There appeared to be a spur on the left inferior aspect and also on the right posterior aspect. The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. After this, the lesion was then removed on the right side with the XPS blade. The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. This area was taken down with the XPS blade. Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter. After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. After this, the patient was then hemostatically controlled with suctioned Bovie cauterization. A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment. The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia. The patient was extubated in the operating room and was transferred to the recovery room in stable condition. The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.surgery, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,

PREOPERATIVE DIAGNOSIS:, Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:, Cervical spondylosis.,OPERATION PERFORMED:, Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:, Ralph Menard, M.D.,ANESTHESIA:, Local and IV.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place. The neck was placed in a flexed position. The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula. The patient was lightly sedated. The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked. Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points. Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned. This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle. For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging. For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process. For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts. Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain. The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level. If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate. Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds. The same procedure was carried out at all the affected levels. The patient tolerated the procedure well without any difficulties or complications.pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation

ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.urology, discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst

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

INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.,SUMMARY:,1. Nondiagnostic adenosine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION:, Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 58% by gated SPECT.radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,

TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:, Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left 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 left metatarsophalangeal joint. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion. A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint. The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw. The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal. The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation. The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal. Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction. The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique. The wires were removed. Fixation on the table was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical. The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw. The area was copiously flushed with saline. The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. The incision site was reinforced with Steri-Strips. At this time, the patient's left ankle tourniquet was deflated. The time was 45 minutes. Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage. The patient's left foot was then placed in a surgical shoe. The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,

Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye. Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD. She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS. Intraocular pressures are 13 OU and by applanation. Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes. Gonioscopy showed normal anterior segment angle morphology in both eyes. She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes. Conjunctivae were quite, OU. Cornea were clear in both eyes. The anterior chamber is deep and quiet, OU. She has clear lenses, which are in good position, OU. Dilated fundus exam shows moderately optically clear vitreous, OU. The optic nerves are normal in size. The cup-to-disc ratios were approximately 0.4, OU. The nerve fiber layers are excellent, OU. The macula, vessels, and periphery were normal in both eyes. No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous. She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur. Otherwise, I can see her in 1 to 2 years.consult - history and phy., systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes."nan

PREOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1. Epidural hematoma, cervical spine.,2. Status post cervical laminectomy, C3 through C7 postop day #10.,3. Central cord syndrome.,4. Acute quadriplegia.,PROCEDURE PERFORMED:,1. Evacuation of epidural hematoma.,2. Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,200 cc.,HISTORY: ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction. She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess. The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change. The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement. Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing. When she examined the patient, she also noted that the patient was unable to move her extremities. She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic. I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma. On clinical examination, there was swelling in the posterior aspect of the neck. The patient has no active movement in the upper and lower extremity muscle groups. Reflexes are absent in the upper and lower extremities. Long track signs are absent. Sensory level is at the C4 dermatome. Rectal tone is absent. I discussed the findings with the patient and also the daughter. We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery. They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE: ,The patient was taken to OR #1 at ABCD General Hospital on a gurney. Department of Anesthesia administered fiberoptic intubation and general anesthetic. A Foley catheter was placed in the bladder. The patient was log rolled in a prone position on the Jackson table. Bony prominences were well padded. The patient's head was placed in the prone view anesthesia head holder. At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound. Next, the patient was prepped and draped in the usual sterile fashion. The previous skin incision was reopened. At this point, hematoma properly exits from the wound. All sutures were removed and the epidural spaces were encountered at this time. The self-retaining retractors were placed in the depth of the wound. Consolidated hematoma was now removed from the wound. Next, the epidural space was encountered. There was no additional hematoma in the epidural space or on the thecal sac. A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac. The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well. Next, the wound was irrigated copiously with one liter of saline using a syringe. The walls of the wound were explored. There was no active bleeding. Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding. A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space. Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures. Steri-Strips covered the incision and dressing was then applied over the incision. The patient was then log rolled in the supine position on the hospital gurney. She remained intubated for airway precautions and transferred to the recovery room in stable condition. Once in the recovery room, she was alert. She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities. Prognosis for this patient is guarded.neurology, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia,

SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago. The patient has required conversion to an open procedure due to difficult anatomy. Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan. The patient is starting to improve, gain more strength. She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS: Clear to auscultation. No wheezes, rales, or rhonchi.,HEART: Regular rhythm and rate.,ABDOMEN: Soft, less tender.,LABORATORY DATA:, Her white count continues to come down. Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000. We have ordered type and cross for 2 units of packed red blood cells. If it drops below 25, she will receive a transfusion. Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7. Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:, She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.soap / chart / progress notes, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis

CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal.,NECK: Nontender, full range of motion, was not examined initially, a collar was placed.,HEART: Regular.,LUNGS: Clear.,CHEST/BACK/ABDOMEN: Without trauma.,SKIN: With multiple excoriations from scratching and itching.,NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.consult - history and phy., alzheimer's, no loss consciousness, mental status,

The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. The abdomen demonstrated some inflammation around the gallbladder. A 10-mm midepigastric trocar was inserted. A. 2 mm and 5 mm trocars were inserted. The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction. The cystic artery was identified and double Hemoclips applied. The gallbladder was taken down from the liver bed using Endoshears and electrocautery. Hemostasis was obtained. The gallbladder was removed from the midepigastric trocar site without difficulty. The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl. Steri-Strips and sterile dressing were placed. The patient tolerated the procedure well and was taken to the recovery room in stable condition.gastroenterology, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: 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.,

SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well. The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72. The patient did undergo echocardiogram, which shows aortic stenosis, severe. The patient does have an outside cardiologist. I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 78 and blood pressure 130/60.,LUNGS: Clear.,HEART: A soft systolic murmur in the aortic area.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema.,IMPRESSION:,1. Status shortness of breath responding well to medical management.,2. Atrial fibrillation, chronic, on anticoagulation.,3. Aortic stenosis.,RECOMMENDATIONS:,1. Continue medications as above.,2. The patient would like to follow with her cardiologist regarding aortic stenosis. She may need a surgical intervention in this regard, which I explained to her. The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,

PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,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 of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,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 a prone position on the treatment table with a pillow under the chest and head rotated. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach. The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3. Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement. Motor stimulation was applied at 2 Hz with 1 millisecond duration. No extremity movement was noted at less than 2 volts. Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached. At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue. After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free. Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS: ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.orthopedic, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,

PREOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed.,PROCEDURE:, The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed, morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed. These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage.,The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated.neurosurgery, anterior spine fusion, posterior spine fusion, spine segmental instrumentation, dry sterile dressings, autograft and allograft, pds sutures, spinous processes, spine fusion, spine, instrumentation, morcellized, allograft, fusion, autograft,

REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physical therapy for his lower back secondary to pain after hernia repair. He states that the pain worsened after this. He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal. He denies any dysuria. He denies any hematemesis. He denies any pleuritic chest pain. He denies any hemoptysis.,PAST MEDICAL HISTORY:,1. History of bilateral hernia repair by Dr. X in 8/2008.,2. History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1. Cipro.,2. Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is afebrile. Pulse 117, respirations 18, and blood pressure 117/55. Saturating 98% on room air.,GENERAL: The patient is alert and oriented x3.,HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear without exudates.,NECK: Supple. No thyromegaly. No jugular venous distention.,HEART: Tachycardic. Regular rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN: Positive bowel sounds. Soft and nontender with no guarding.,EXTREMITIES: No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC: Nonfocal.,LABORATORY STUDIES:, Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils. EKG shows sinus tachycardia.,PROBLEM LIST:,1. Colitis.,2. Sepsis.,3. Rectal bleeding.,RECOMMENDATIONS:,1. GI consult with Dr. Y's group.,2. Continue Levaquin and Flagyl.,3. IV fluids.,4. Send for fecal WBCs, O&P, and C. diff.,5. CT of the abdomen and pelvis to rule out abdominal pathology.,6. PPI for PUD prophylaxis.nan