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PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition.surgery, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1. Onychocryptosis.,podiatry, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

PREOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:, General.,FINDINGS:, The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a great deal of inflammatory reaction around the cystic duct. The cystic duct was slightly larger. There was a stone impacted in the cystic duct with the gallbladder. The gallbladder contained numerous stones which were small. With the stone impacted in the cystic duct, it was felt that probably none were within the common duct. Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:, Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully. Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. In this manner, the cystic duct and cystic artery were dissected out. Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. The gallbladder was then dissected free from the gallbladder bed. Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. The gallbladder was extracted through the operating trocar site, and the trocar was reinserted. Inspection was made of the gallbladder bed. One or two bleeding areas were fulgurated, and bleeding was well controlled.surgery, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory

HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy. The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours). The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors. The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.radiology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: 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.

Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. surgery, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominalNOTE,: 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.,

PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago. ,SOCIAL HISTORY:, He is currently single. He has about ten drinks a year. He had smoked significantly up until several months ago. He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:, He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program. He had a poor experience with the Greenwich program. Eating history, he is not an emotional eater. Does not like sweets. He likes big portions and carbohydrates. He likes chicken and not steak. He currently weighs 312 pounds. Ideal body weight would be 170 pounds. He is 142 pounds overweight. If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin. Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3. Cranial nerves II-XII are intact. Afebrile. Vital Signs are stable.consult - history and phy., laparoscopic gastric bypass, weight loss programs, gastric bypass, atkin's diet, weight watcher's, body weight, laparoscopic gastric, weight loss, pounds, months, weight, laparoscopic, band, loss, diets, overweight, lost

ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:, Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:, None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident. He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters. The patient denies any loss of consciousness. He was not amnestic to the event. He was taken by family members to the Iredell County Hospital, where he was initially evaluated. Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture. No other apparent injuries. This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment. The left upper extremity x-ray did demonstrate an open left distal humerus fracture. The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture. In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture. In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures. Throughout the duration of the procedure, the patient had a palpable distal radial pulse. The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture. A wound VAC was then placed over the wound at the conclusion of the procedure. The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring. His diet was advanced and his pain was controlled with pain medication. The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident. A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point. Once his C spine had been cleared and the absence of a closed head injury was confirmed. The patient was then transferred from the Intensive Care Unit to the General Floor bed. His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound. He again tolerated this procedure well on his return to the General Pediatrics Floor. Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries. However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity. Moreover, the patient had no complaints of paresthesia. There was no demonstration of pallor or pain on passive motion. There was good capillary refill to the digits of the left hand. By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well. He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies. He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1. Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2. Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3. Negative pressure wound dressing (July 23, 2008).,4. Irrigation and debridement of left elbow fracture (July 26, 2008).,5. CT of the brain without contrast (July 24, 2008).,DISPOSITION: ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS: ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity. He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics. Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.orthopedic, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture,

PREOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,POSTOPERATIVE DIAGNOSIS:,1. Left chronic anterior and posterior ethmoiditis.,2. Left chronic maxillary sinusitis with polyps.,3. Left inferior turbinate hypertrophy.,4. Right anterior and posterior chronic ethmoiditis.,5. Right chronic maxillary sinusitis with polyps.,6. Right chronic inferior turbinate hypertrophic.,7. Intranasal deformity causing nasal obstruction due to septal deviation.,NAME OF OPERATION: , Bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 20 cc.,HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis. She also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. After adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum. Approximately 10 cc total was used.,A #15 blade and the Freer elevator were used to help make a standard hemitransfixion incision. A mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the Freer elevator. The bony deflection was removed using Jansen-Middleton forceps. The cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest. The initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,Attention then was directed toward the left side. Lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps. Approximately 10 cc total was used. The polyps were removed using the Richards essential shaver to help identify the middle turbinate and uncinate process better. The uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. Next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site. The sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,The anterior and posterior ethmoid air cells were entered primarily and dissected with the Richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection. Bright mucosal disease and small polypoid accumulations were noted through the sinuses also. The inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy. The mucosal polypoid accumulations were cleared using the Richards essential shaver. The turbinate was partially resected from mucosally but with good shape to it. It was not desirable to remove it in its entirety. Any obvious bleeding points along the edge were controlled with the suction Bovie apparatus.,The same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used. The polyps were removed. The Richards essential shaver was used to allow better exposure of the uncinate process. The uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,Next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also. The anterior and posterior ethmoid air cells were then entered primarily and dissected with Richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection. The inferior turbinates showed mucosal disease, polypoid accumulations, and changes. These were removed using the Richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,Any obvious bleeding points were controlled with the suction Bovie apparatus. A thorough irrigation was then carried out in the nasal cavity, and Gelfilm packing was used to coat the linings in the middle meatal regions. The patient tolerated the procedure well and returned to the recovery room in stable condition.nan

PREOPERATIVE DIAGNOSIS: , Right breast mass with atypical proliferative cells on fine-needle aspiration.,POSTOPERATIVE DIAGNOSIS:, Benign breast mass.,ANESTHESIA: , General,NAME OF OPERATION:, Excision of right breast mass.,PROCEDURE:, With the patient in the supine position, the right breast was prepped and draped in a sterile fashion. A curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast. Dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue. Hemostasis was obtained using electrocautery. Frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign. The breast tissues were approximated using 4-0 Vicryl. The skin was closed using 5-0 Vicryl running subcuticular stitches. A sterile bandage was applied. The patient tolerated the procedure well.,obstetrics / gynecology, atypical proliferative cells, fine needle aspiration, proliferative cells, breast mass, breast, needle, aspiration, fibroadenoma, excision, proliferative, mass,

PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:, Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:, General.,FINDINGS AND PROCEDURE:, With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion. After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus. Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen. A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood. Attention was then directed to the thighs both inner and outer. A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs. After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh. The patient tolerated the procedure very well. All of this aspirate was mostly fat with little fluid and very little blood. Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied. The patient tolerated the procedure very well and was sent to the recovery room in good condition.surgery, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs,

PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage. Currently, he has a fistula from his anterior abdominal wall out. It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall. CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease. Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS: ,General anesthesia.,INSTRUMENT:, Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia. The endoscope was inserted without difficulty into the hypopharynx. The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern. Lower esophageal sphincter was located at 40 cm from the central incisors. It appeared normal and appeared to function normally. The endoscope was advanced into the stomach, which was distended with excess air. Rugal folds were flattened completely. There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach. The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern. Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology. Two additional biopsies were obtained in the antrum for CLO testing. Excess air was evacuated from the stomach. The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy. Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock. The colonoscope was then inserted into the anal verge. The colonic clean out was excellent. The scope was advanced without difficulty to the cecum. The cecal area had multiple ulcers with exudate. The ileocecal valve was markedly distorted. Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum. The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon. Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm. No fistulas were noted in the colon. Excess air was evacuated from the colon. The scope was removed. The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum. There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve. All these findings are consistent with Crohn's disease.,PLAN: ,Begin prednisone 30 mg p.o. daily. Await PPD results and chest x-ray results, as well as cocci serology results. If these are normal, then we would recommend Remicade 5 mg/kg IV infusion. We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy. Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate. We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula. He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy. If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.surgery, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy

MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits. The patient appeared alert.,EYES: , The conjunctiva was clear. The pupil was equal and reactive. There was no ptosis. The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance. Hearing was grossly intact. The oropharynx showed that the mucosa was moist. There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple. The thyroid gland was not enlarged by palpation.,RESPIRATORY: ,The patient's respiratory effort was normal. Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted. The extremities showed no edema.,BREASTS: ,Breast inspection showed them to be symmetrical with no nipple discharge. Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL: ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen. Bowel sounds were present.,GU: ,The external genitalia appeared to be normal. The pelvic exam revealed no adnexal masses. The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC: ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL: ,The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.,SKIN:, Inspection of the skin and subcutaneous tissues appeared to be normal. The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.,PSYCHIATRIC: ,The patient was oriented to time, place and person. The patient's judgment and insight appeared to be normal.

CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag." According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch. The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. The patient also complains of the development of an incisional hernia since his surgery in November. He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X. Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Question of hypertension.,3. Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4. Status post cholecystectomy.,7. Status post unknown foot surgery.,MEDICATIONS:, None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro. He smokes one pack of cigarettes a day and has done so for 15 years. He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY: ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL: This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Moist mucous membranes. Extraocular movements intact.,NECK: Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR: Regular rate and rhythm.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Soft, nontender, and nondistended with a left lower quadrant stoma. The stoma is pink, protuberant, and productive. The patient also has a midline incisional hernia approximately 6 cm in diameter. It is reducible. Otherwise, there are no further hernias or masses noted.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN: ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis. The patient presents for reversal of his colostomy as well as repair of his incisional hernia. I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery. He stated that he would try and do this and bring the records to our clinic on his next appointment. I have also set him up for a barium enema to study the rectal stump. He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. This was discussed with the patient as well as his sister and significant other in the clinic today. They were in agreement with this plan. We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,nan

SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:, She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight.general medicine, antibiotics, febrile seizure, temperature, blood count, white count, pneumonia, seizure,

PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE: ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS: ,Same as above.,ANESTHESIA: ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:, No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION: ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection. Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified. Once he was anesthetized, the caudal block was placed and IV antibiotics were given. He was then placed in a supine position and sterilely prepped and draped. Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors. We removed the excessive skin on the shaft skin and on the glans itself. We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic. Electrocautery was used for hemostasis. Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again. IV Toradol was given at the end of procedure. The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.urology, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

INDICATION FOR OPERATION:, Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:, Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:, After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner. Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture. Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion. Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally. The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar. We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal. The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs. On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof. The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate. It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position. The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place. Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place. The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum. The wounds were irrigated out. A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings. The patient tolerated the procedure well and did receive blood transfusions.neurosurgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,

PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:, Tiny Polyps.,PROCEDURE PERFORMED: , Colonoscopy.,PROCEDURE: , The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination. ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum. It was passed to the level of the cecum. The ileocecal valve was identified, as was the appendiceal orifice. ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon. This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps. In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon. This was also removed using the cold biopsy forceps. Further detail failed to reveal any other lesions with the exception of small hemorrhoids. ,IMPRESSION: , Tiny polyps. ,PLAN: , If adenomatous, repeat exam in five years. Otherwise, repeat exam in 10 years.,surgery, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy

PROCEDURE IN DETAIL:, After written consent was obtained from the patient, the patient was brought back into the operating room and identified. The patient was placed on the operating room table in supine position and given anesthetic.,Once adequate anesthesia had been achieved, a careful examination of the shoulder was performed. It revealed no patholigamentous laxity. We then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax. The shoulder was then prepped and draped in the usual sterile fashion. We then injected the glenohumeral joint with 60 cc of sterile saline solution. A small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion. Through this incision, a blunt trocar was placed.,We then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution. An anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,We found that the articular surface was in good condition. The biceps was found to be intact. There was a SLAP tear noted just posterior to the biceps. Pictures were taken. No Bankart or Hill-Sachs lesions were noted. The rotator cuff was examined and there were no undersurface tears. Pictures were again taken.,We then made a lateral portal going through the muscle belly of the rotator cuff. A drill hole was made and then knotless suture anchor was placed to repair this. Pictures were taken. We then washed out the joint with copious amounts of sterile saline solution. It was drained. Our 3 incisions were closed using 3-0 nylon suture. A pain pump catheter was introduced into the shoulder joint. Xeroform, 4 x 4s, ABDs, tape, and sling were placed.,The patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition. I then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.surgery, laxity, patholigamentous, superior labrum, saline solution, anterior, superior, lesions, repair, sterile, joint, shoulder,

PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED: ,Total hip arthroplasty on the left.,ANESTHESIA: ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS: ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis. This was revealed once we removed the trochanteric bursa.,HISTORY: ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis. She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure. All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure. The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03. The general anesthetic was first performed by the Department of Anesthesia. The patient was then positioned with the left hip exposed on the beanbag in the lateral position. Kidney rests were also used because of the patient's size. An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse. All her bony prominences were well padded. At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure. At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat. The tensor fascia lata was then identified. A self-retainer was then inserted to expose the operative field. Bovie cautery was used for hemostasis. At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter. At this time, a blunt dissection was taken proximally. The tensor fascia lata was occluded with a hip retractor. At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius. At this time, a periosteal elevator was used to expose anterior hip capsule. A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle. Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck. At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum. At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum. At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum. At this time, a femoral stem guide was then used to measure proximal femoral neck cut. We made a cut approximately a fingerbreadth above the lesser trochanter. At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed. At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum. A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum. With better exposure of the acetabulum, we started reaming the acetabulum. We started with a size #44 and progressively reamed to a size #50. At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum. We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum. A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in. Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum. At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup. At this time, a plastic liner was then inserted for protection. The leg was then placed back in the bag. A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur. A rongeur was used to lateralize over the greater trochanter. A Box osteotome was used to remove the cancellous portion of the femoral neck. A Charnley awl was then used to cannulate through the proximal femoral canal. A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem. At this time, we began broaching. We started with a size #10 and progressively worked up to a size #12 mm broach. Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar. A calcar reamer was then placed and the calcar was reamed smoothly. A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed. Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation. At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum. This was impacted and placed and checked to assure that it was well seated with no loosening. Once this was performed, we then exposed the proximal femur one more time. We copiously irrigated within the canal and then suctioned it dry. At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place. Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none. The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion. We were satisfied with components as well as the alignment of the components. Copious irrigation was then used to irrigate the wound. #1 Ethibond was then used to approximate the anterior hip capsule. #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter. Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure. A tight closure was performed. Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin. Staples were then used for skin closure. The patient's hip was then cleansed. Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed. A drain was placed prior to wound closure for postoperative drainage. After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition. Prognosis is good.orthopedic, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,

SUBJECTIVE:, The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,OBJECTIVE:,General: The patient is a very pleasant 44-year-old white female quite obese.,Vital Signs: Blood pressure: 122/70. Temperature: 98.6.,HEENT: Head: Normocephalic. Ears: TMs intact. Eyes: Pupils round, and equal. Nose: Mucosa normal. Throat: Mucosa normal.,Lungs: Clear.,Heart: Regular rate and rhythm.,Abdomen: Soft and obese.,Extremities: A lot of fluid in both legs, but especially the left leg is really swollen. At least 2+ pedal edema. The right leg just has a trace of edema. She has pain in her low back with range of motion. She has a lot of pain in her left shoulder with range of motion. It is hard for her to get her hand behind her back. She cannot get it up behind her head. She has pain in the anterior left shoulder in that area.,ASSESSMENT:,1. Multiple problems including left leg swelling.,2. History of leukocytosis.,3. Joint pain involving the left shoulder, probably impingement syndrome.,4. Low back pain, chronic with obesity.,5. Obesity.,6. Frequency with urination.,7. Tobacco abuse.,PLAN:,1. I will schedule for a venous Doppler of the left leg and will have her come back in the morning for a CBC and a metabolic panel. We will start her on Detrol 0.4 mg one daily and also started on Mobic 15 mg per day.,2. Elevate her leg as much as possible and wear support hose if possible. Keep her foot up during the day. We will see her back in two weeks. We will have the results of the Doppler, the lab work and see how she is doing with the Detrol and the joint pain. If her shoulder pain is not any better, we probably should refer her on over to orthopedist. We did do x-rays of her shoulder today that did not show anything remarkable. See her in two weeks or p.r.n.general medicine, leg swelling, leukocytosis, joint pain, left shoulder, low back pain, obesity, frequency with urination, tobacco abuse, multiple problems, blood count, blood pressure, leg, shoulder, tobacco, swelling, weight

REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:, Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3. Pupils equal and reactive. EOMs are full. Motor is 5 out of 5. She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus. There is no evidence of clonus. There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord. I had a thorough discussion with the patient and her parents. I have recommended a repeat MRI scan. The prescription was given today. MRI of the lumbar spine was just completed. I would like to see her back in clinic. We did discuss the possible symptoms of this tethering.neurology, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,

INDICATIONS:, Dysphagia.,PREMEDICATION:, Topical Cetacaine spray and Versed IV.,PROCEDURE:,: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The scope was passed on down into the stomach. The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen. The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable. The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present. The scope was then withdrawn.,IMPRESSION:, Normal upper GI endoscopy without any evidence of anatomical narrowing.gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope

PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done. Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed. Coronary arteriography was performed with 6-French performed coronary catheters. We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries. After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery. A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg. On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve. The aortic pressures were normal. Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:, Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta. A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position. The mitral valve is competent and demonstrates normal mobility. The left ventricular cavity is normal in size with excellent contractility. Aneurysmal dilatation and/or dyskinesia absent. The aortic valve is tricuspid and normal mobility. The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries. An abdominal aortic injection was performed. Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation. There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis. The abdominal aortogram reveals wide patency of that area with mild intimal irregularity. There is a normal left renal artery, normal right renal artery. The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal. The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:, One notes ostial coronary calcification of the right coronary artery. Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters. Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually. The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%. There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery. In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third. Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel. The distal portion of the vessel is free of disease. The conus branch is seen arising right at the beginning part of the right coronary artery. We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%. At the ostium of the right coronary artery, calcification again is identified. Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis. It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment. There appears to be some mild stenosis of 10% in the proximal segment. It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease. The remaining portion of the left anterior descending artery is free of disease. Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed. I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system. There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well. The catheter was removed. Hemostasis was achieved. The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1. Excellent left ventricular contractility with normal left ventricular cavity size.,2. Calcification of the mid abdominal aorta with wide patency of all vessels. The left and right renal arteries are normal. The external iliac arteries are normal.,3. Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4. Ostial stenosis of the right coronary artery that appears to be about 50% or greater. The proximal right coronary artery has 50% stenosis as well.,5. Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS: ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed. The ostial lesion of the right coronary artery may be severe. It is at least 50%, but it could be worse. Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery. We will reevaluate her stress nuclear study as well. Continue aggressive medical therapy.cardiovascular / pulmonary, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery,

PREOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1. Herniated nucleus pulposus, C5-C6.,2. Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1. Anterior cervical decompression, C5-C6.,2. Anterior cervical decompression, C6-C7.,3. Anterior spine instrumentation.,4. Anterior cervical spine fusion, C5-C6.,5. Anterior cervical spine fusion, C6-C7.,6. Application of machined allograft at C5-C6.,7. Application of machined allograft at C6-C7.,8. Allograft, structural at C5-C6.,9. Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE: ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness. Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left. The patient has failed epidural steroid injections. Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position. After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion. A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body. It was taken down through the subcutaneous tissues exposing the platysmus muscle. The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine. An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level. Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed. The disk was very degenerated and brown in color. There was an acute disk herniation through posterior longitudinal ligament. The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed. Approximately, 5 mm of the nerve root on both the right and left side was visualized. A ball-ended probe could be passed up the foramen. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place. There was good bony apposition both proximally and distally. Next, attention was placed at the C6-C7 level. Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed. The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left. The posterior longitudinal ligament was removed. A bilateral foraminotomy was performed. Approximately, 5 mm of the C7 nerve root was visualized on both sides. A micro nerve hook was able to be passed up the foramen easily. Bleeding was controlled with bipolar electrocautery and Surgiflo. The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place. There was good bony apposition, both proximally and distally. Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws. Intraoperative x-ray confirmed appropriate positioning of the plate and the graft. The wound was then copiously irrigated with normal saline and bacitracin. There was no active bleeding upon closure of the wound. A small drain was placed deep. The platysmal muscle was closed with 3-0 Vicryl. The skin was closed with #4-0 Monocryl. Mastisol and Steri-Strips were applied. The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events. The patient was awoken and taken to the recovery room in satisfactory condition.neurosurgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,

SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:, The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.,PLAN:, The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005.soap / chart / progress notes, weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food

CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:, T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.nan

PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:, Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:, None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma. She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X. It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters. Consent was obtained. The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted. A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression. She tolerated this procedure very well.ent - otolaryngology, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage

INDICATIONS FOR PROCEDURE:, Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1. Demerol 50 mg.,2. Phenergan 25 mg.,3. Atropine 0.6 mg IM.,4. Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:, With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords. The cords move normally with phonation and ventilation. Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed. Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. Upper lobe and lingula were unremarkable. There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. This had been a change from the prior bronchoscopy of unclear significance. Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic. The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. The scope was withdrawn. The patient's saturation remained 93%-95% throughout the procedure. Blood pressure was 103/62. Heart rate at the end of the procedure was about 100. The patient tolerated the procedure well. Samples were sent as follows. Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture. Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture.cardiovascular / pulmonary, cough, bronchoscopy, olympus, bronchoscope, nasal insufflation, oral antibiotics, pulse oximetry, sputum, ventilation, antibiotics, nocardia, aspergillus, chlamydia, atropine, lidocaine, cords, topical,

LONG-TERM GOALS:, Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community. This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home. During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill. She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued. The patient and her husband both agreed with the patient's discharge.speech - language, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: 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:, Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE: ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended. Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain. A catheter was inserted in the nose and brought out from mouth. The throat was irrigated with saline. There was no further bleeding. The patient was awakened and extubated and moved to the recovery room in satisfactory condition.surgery, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy

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

HISTORY:, Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.,GENERAL: This is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.,EYES: Conjunctivae are now pink.,ENT: Oropharynx is clear.,CARDIOVASCULAR: Reveals distant heart tones with regular rate and rhythm.,LUNGS: Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,ABDOMEN: Soft and nontender with no organomegaly appreciated.,EXTREMITIES: Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.,NEUROLOGICAL: Cranial nerves II through XII are grossly intact with no focal neurological deficits.,LABORATORY DATA:, Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,IMPRESSION/PLAN,1. Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.,4. Anemia, normochromic normocytic with low total iron binding capacity. This appears to be anemia of chronic disease. However, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.general medicine, anemia, gi bleeding, hemoglobin, ulcerative, esophagitis, obstructive pulmonary disease, icu followup, infection, obstructive, pulmonary, egd, melena, bleeding

EXAM: , Modified barium swallow.,SYMPTOM:, Dysphagia with possible aspiration.,FINDINGS:, A cookie deglutition study was performed. The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of penetration with thin liquids. This is not evident with thick liquids, semisolids or solids.,There is weakness in the oral phase of deglutition. Subglottic region appears normal. There is no evidence of aspiration demonstrated.,IMPRESSION: , Penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.radiology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition,

PREOPERATIVE DIAGNOSIS: , Necrotizing infection of the left lower abdomen and left peritoneal area.,POSTOPERATIVE DIAGNOSIS:, Necrotizing infection of the left lower abdomen and left peritoneal area.,PROCEDURE PERFORMED:, Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,ANESTHESIA:, General.,FLUIDS:, 800 cc given.,ESTIMATED BLOOD LOSS: ,350 cc.,SPECIMEN,: Pannus and left peritoneal specimen sent to Pathology.,REASON FOR PROCEDURE:, This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin. The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control. He has had a groin abdominal wound drained for about four days. The patient states that there has been pus that has saturated his sheath. He has had a possible fever at home that he did not chart with a thermometer. He has had the same groin infection twice in the past with tunneling lesions. The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day. Bowel habits and eating were essentially normal.,Urinary habits were normal. The patient is morbidly obese and is approximately 450 lb. He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,PAST MEDICAL HISTORY:, Diabetes, morbid obesity, and nephrolithiasis.,PAST SURGICAL HISTORY:, Appendectomy and stone extraction.,PROCEDURE: , The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture. The patient had a white count of 11.4 and a hemoglobin of 13.4. Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products. The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted. In the operative suite, he was prepped and draped in the usual sterile fashion. The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen. Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized. Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis. Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated. The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards. The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis. The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia. The necrotic tissue was lifted out of the abdomen. All bleeding was cauterized using the Bovie. A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned. A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing. The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm. The tissue was incised to the muscle layer of the muscle. There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well. There was a mild amount of pus that drained from the wound. Cultures were taken from the groin wound and were sent to pathology. The specimen was excised using traction with the Allis clamps as well as Bovie set on coag. Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit. After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.,It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date. The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology. The patient tolerated the procedure well and was taken to recovery in good condition.surgery, debridement, abdomen, peritoneal, pannus, pathology, necrotizing infection, necrotic tissue, tissue, infection, necrotizing, groin, wound,

CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic. The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed. The capsulorrhexis was then performed in a standard circular tear fashion. The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag. The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic. The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization. The lens was noted to center well. The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution. The eye was then checked and found to be watertight; therefore, no suture was used. The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.ophthalmology, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: 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: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE: ,Adenotonsillectomy.,COMPLICATIONS:, None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed. The adenoid bed was examined and was moderately hypertrophied. Adenoid curettes were used to remove this tissue and packs placed. Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed. A similar procedure was performed on the contralateral tonsil. Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted. The patient was then allowed to awaken and was brought to the recovery room in stable condition.surgery, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,

CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a " bulging disk" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL: The patient appears to be comfortable, in no acute distress.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush.,NECK: Trachea is at the midline.,LYMPHATICS: No cervical or axillary nodes palpable.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Obese, softly protuberant, and nontender.,EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5.,MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination.,ASSESSMENT:,1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.nan

EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a "high ankle sprain" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.nan

PROCEDURE:, Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing. This was felt to be related largely to chronic obstructive lung disease. She had dynamic T-wave changes in precordial leads. Cardiac enzymes were indeterminate. She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail. The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory. Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped. Local anesthesia was obtained with 2% Xylocaine. The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel. Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed. Ascending aortic root pressures obtained. This catheter was utilized in an attempt to cannulate the left coronary ostium. This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta. The catheter appropriately aspirated and flushed. The catheter was advanced in the right coronary artery. Multiple views of that vessel were obtained. The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained. This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta. The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds. Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve. Videotapes were then reviewed. It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out. Excellent hemostasis was obtained. The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1. ,HEMODYNAMICS:, Left ventricular end-diastolic filling pressure was 24. There was no gradient across the aortic valve.,2. ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function. Mild inferobasilar hypokinesis was noted. No significant mitral regurgitation noted. Ejection fraction was estimated at 60%.,3. ,CORONARY ARTERIOGRAPHY,A. ,LEFT MAIN CORONARY: , The left main coronary was patent.,B. ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C. ,CIRCUMFLEX CORONARY ARTERY:, Circumflex coronary artery was occluded at its origin.,D. ,RIGHT CORONARY ARTERY,. Right coronary artery was occluded in its mid portion.,4. ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A. ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites. Excellent flow was noted in the diagonal system with some retrograde flow.,B. There was retrograde flow as well in the left anterior descending system.,C. ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:, Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites. There was no graft disease noted. Excellent flow was noted in the bifurcating marginal system.,D. ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:, Saphenous vein graft to right coronary was widely patent with no graft disease. Origin and insertion sites were free of disease. Distal flow in the graft to the posterior descending was normal.,5. ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites. There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel. Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1. Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.nan

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

There is normal and symmetrical filling of the caliceal system. Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally. The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:, Negative intravenous urogram.,nephrology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: 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.,

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation. She is suffering from ongoing myofascitis. Her treatment plan will consist of a series of trigger point injections, which were performed today. She tolerated the procedure well. I have asked her to ice the region intermittently for 15 minutes off and on x 3. She will be followed in four weeks' time for repeat trigger point injections if indicated.,orthopedic, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: 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:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up.nan

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.nan

REASON FOR CONSULT: , Medical management, status post left total knee arthroplasty.,PAST MEDICAL HISTORY:,1. Polyarthritis.,2. Acromegaly.,3. Hypothyroidism.,4. Borderline hypertension.,5. Obesity.,PAST SURGICAL HISTORY: , Hernia repair, resection of tumor, right thumb arthrodesis, carpal tunnel decompression, bilateral hip replacement, right total knee replacement about 2 months ago, open reduction of left elbow fracture.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS: No fever or recent general malaise.,ENT: Not remarkable.,RESPIRATORY: No cough or shortness of breath.,CARDIOVASCULAR: The patient denies any heart problems. No orthopnea. No palpitations. No syncopal episodes.,GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: The patient is status post pituitary tumor resection and is on supplemental hormone.,MEDICATIONS: Depo-Testosterone 200 mg IM q.3 weekly, prednisone 1 tablet p.o. daily, octreotide IM on a monthly basis, morphine extended release 50 mg p.o. b.i.d., Synthroid 100 mcg p.o. daily, desmopressin 1 tablet p.o. every bedtime, aspirin/oxycodone on a p.r.n. basis, aspirin on p.r.n. basis.,ALLERGIES: , IBUPROFEN AND TYLENOL.,SOCIAL HISTORY: , The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION,GENERAL: Obese, 57-year-old gentleman, not in acute distress.,VITAL SIGNS: Blood pressure of 105/55, pulse is 90. He is afebrile. O2 saturation is 95% on room air.,HEAD AND NECK: Face symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated.,ABDOMEN: Benign.,EXTREMITIES: The left knee is in closed dressing. The lower extremities are still numb from spinal anesthesia.,ASSESSMENT AND PLAN:,1. Polyarthritis, status post left total knee replacement. The patient tolerated the procedure well.,2. Acromegaly, status post pituitary resection. Continue supplemental hormones.,3. Borderline hypertension, blood pressure is under control with monitoring.,4. Deep venous thrombosis prophylaxis as per surgeon.,5. Anemia due to repeated blood loss with monitor hemoglobin and hematocrit.nan

SUBJECTIVE: , This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom. He has a history of doing heroin. He was injecting into his vein. He was seeing a physician in the city. They were prescribing methadone for some time. He says that did help. He was on 10 mg of methadone. He was on it for three to four months. He tried to wean down on the methadone a couple of different times, but failed. He has been intermittently using heroin. He says one of the big problems is that he lives in a household full of drug users and he could not get away from it. All that changed now that he is living with his mom. The last time he did heroin was about seven to eight days ago. He has not had any methadone in about a week either. He is coming in today specifically requesting methadone. He also admits to being depressed. He is sad a lot and down. He does not have much energy. He does not have the enthusiasm. He denies any suicidal or homicidal ideations at the present time. I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms. His past medical history is significant for no medical problems. Surgical history, he voluntarily donated his left kidney. Family and social history were reviewed per the nursing notes. His allergies are no known drug allergies. Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken. General: He is nontoxic and in no acute distress. Psychiatric: Alert and oriented times 3. Skin: I examined his upper extremities. He showed me his injection sites. I can see marks, but they seem to be healing up nicely. I do not see any evidence of cellulitis. There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom. I am not prescribing him any narcotics or controlled substances. I am not in the practice of trading one addiction for another. It has been one week without any sort of drugs at all. I do not think he needs weaning. I think right now it is mostly psychological, although there still could be some residual physical addiction. However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time. I do believe that his depression needs to be treated. I gave him fluoxetine 20 mg one tablet daily. I discussed the side effects in detail. I did also warn him that all antidepressant medications carry an increased risk of suicide. If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately. If he has any problems or side effects, he was also directed to call me here at the office. After-hours, he can go to the emergency room or call #911. I am going to see him back in three weeks for the depression. I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group. We are unable to make a referral for him to do that. He has to call on his own. He has no insurance. However, I think fluoxetine is very affordable. He can get it for $4 per month at Wal-Mart. His mom is going to keep an eye on him as well. He is going to be staying there. It sounds like he is looking for a job.general medicine, addicted to drugs, substance abuse, abuse, heroin, methadone

HISTORY OF PRESENT ILLNESS: , Patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain. She has had a dry cough and a fever as high as 100, but this has not been since the first day. She denies any vomiting or diarrhea. She did try some Tylenol Cough and Cold followed by Tylenol Cough and Cold Severe, but she does not think that this has helped.,FAMILY HISTORY: , The patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,REVIEW OF SYSTEMS:, The patient does note some pressure in her sinuses. She denies any skin rash.,SOCIAL HISTORY:, Patient lives with her mother, who is here with her.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits. Room air oximetry is 100%.,GENERAL: Patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,HEENT: Head is normocephalic, atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. Both TMs are easily visualized and are clear with good light reflex and no erythema. Sinuses do show some mild tenderness to percussion.,NECK: No meningismus or enlarged anterior/posterior cervical lymph nodes.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,SKIN: No rash.,ASSESSMENT:, Viral upper respiratory infection (URI) with sinus and eustachian congestion.,PLAN:, I did educate the patient about her problem and urged her to switch to Advil Cold & Sinus for the next three to five days for better control of her sinus and eustachian discomfort. I did urge her to use Afrin nasal spray for the next three to five days to further decongest her sinuses. If she is unimproved in five days, follow up with her PCP for re-exam.consult - history and phy., upper respiratory infection, eustachian congestion, erythema, uri, nasal, cough, eustachian, respiratory, sinus, congestion, infection, tonsillar

CHIEF COMPLAINT:, Toothache.,HISTORY OF PRESENT ILLNESS: ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:, PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1. ODONTALGIA.,2. MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION: ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.emergency room reports, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information. She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history. On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY: ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:, Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY: ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS: Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL: She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT: Atraumatic.,NECK: Soft and supple.,LUNGS: Bilaterally diminished.,HEART: Regular.,ABDOMEN: Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift. Elevated AST at 138, with a normal ALT at 38. Alkaline phosphatase of 96, bilirubin 0.8. Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:, Have her admitted to the medical service for treatment of her hyponatremia.nan

HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got here, she was in severe pain and had fever. They came straight to the emergency room. She was admitted. She had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. Multiple blood studies have been done including cultures, febrile agglutinins, etc. She has had run a higher blood glucose to the normal and she has been on sliding scale insulin. She was not known previously to be a diabetic. All x-rays have not been helpful as far as to determine the etiology of her discomfort. MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.,PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: , She was not known to be a diabetic until this admission. She had been hypertensive. She has been on medications and has been controlled. She has not had hyperlipidemia. She has had no thyroid problems. There has been no asthma, bronchitis, TB, emphysema or pneumonia. No tuberculosis. She has had no breast tumors. She has had no chest pain or cardiac problems. She has had gallbladder surgery. She has not had any gastritis or ulcers. She has had no kidney disease. She has had a hysterectomy. She has had 9 pregnancies and 8 living children. She had A&P repair. She had a sacral abscess after a spinal. It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal. There have been fractures and no significant arthritis. She has been quite active at her ranch in Mexico. She raises goats and cattle. She drives a tractor and in short, has been very active.,PHYSICAL EXAMINATION:, She is a short female, alert. She is shivering. She has ice in her axilla and behind her neck. She is febrile to 101 degrees F. She is alert. Her complaint is that of hip pain in the posterior sacroiliac joint area. She moves both her upper extremities well. She can move her right leg well. She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint. She cannot stand, sit or turn without severe pain. She has normal knee reflexes. No ankle reflexes. She has bounding tibial pulses. No sensory deficit. She says she knows when she has to void. She has a healed scar in the upper sacral region. There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.,PLAN: , My plan is to do a triple-phase bone scan. I am suspecting an infection possibly in the left sacroiliac joint. It is probably some type of bacterium, the etiology of which is undetermined. She has had a normal white count despite her fever. There has been a history of brucellosis in the past, but her titers at this time are negative. Continue medication which included antibiotics and also the Motrin and Darvocet.,general medicine, inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,

HISTORY OF PRESENT ILLNESS:, The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. She states that she has not voided in the last 24 hours as well due to pain. She denies any leaking of fluid, vaginal bleeding, or uterine contractions. She reports good fetal movement. She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only. Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant. She continues to yell out for requesting pain medication and about how much "it hurts.",PAST MEDICAL HISTORY:,1. Irritable bowel syndrome.,2. Urinary tract infections times three. The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:, Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day. Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits. Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old. G2 is current. Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use. She endorses marijuana use and a history of cocaine use five years ago. Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS: Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit. Fetal heart tones are 130s with moderate long-term variability. No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL: Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR: Regular rate and rhythm.,PULMONARY: Clear to auscultation bilaterally.,BACK: Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN: Tender to palpation in left lower quadrant. No guarding or rebound. Normal bowel sounds.,EXTREMITIES: Scar track marks from bilateral arms.,PELVIC: External vaginal exam is closed, long, high, and posterior. Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279. CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6. Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN: ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation. I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery. Plans are made for transfer at this time. This was discussed with Dr. Y who is in agreement with the plan.nan

GENERAL: ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX. Height XXX, weight XXX.,HEAD: , Normocephalic. Negative lesions, negative masses.,EYES: , PERLA, EOMI. Sclerae clear. Negative icterus, negative conjunctivitis.,ENT:, Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. Negative ear obstructions, negative exudates. Negative inflammation in external auditory canals. Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers. No tattoos.,NECK:, Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:, Regular rate and rhythm. Negative rubs, negative gallops, negative murmurs.,LUNGS:, Clear to auscultation. Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds. Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. Pulses adequate bilaterally.,MUSCULOSKELETAL:, Negative muscle atrophy, negative masses. Strength adequate bilaterally. Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact. Negative gait disturbance. Balance and coordination intact. Negative Romberg, negative Babinski. DTRs equal bilaterally.,GENITOURINARY: ,Deferred.,

SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D.rheumatology, 1 cc of lidocaine, epicondylitis, kenalog, kenalog mixed with 1 cc of lidocaine, progress note, aches and pains, history of lupus, lidocaine, lupus, methotrexate, kenalog mixed, injected,

ADMITTING DIAGNOSES:, Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4. During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS: ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed. A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty. Plan was to remove the stent. At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement. He has had no recent cold or flu. He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies. Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:, A 14-organ system review of systems is negative except for the history of present illness. He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:, Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL: The patient is an active little boy.,HEENT: The head and neck exam was grossly normal. He had no oral, ocular, or nasal discharge.,LUNGS: Exam was normal without wheezing.,HEART: Without murmur or gallops.,ABDOMEN: Soft, without mass or tenderness with a well-healed flank incision.,GU: Uncircumcised male with bilaterally descended testes.,EXTREMITIES: He has full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,BACK: He has normal back. Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy. He was made NPO. He had a fever at first time with elevated creatinine. He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure. Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty. He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy. The patient had draining nephrostomy tube without difficulty.,nan

CHIEF COMPLAINT: ,Hip pain.,HISTORY OF PRESENTING ILLNESS: ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office. She reports moderate to severe pain related to a complicated past medical history. In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23. She was given nonsteroidals at that time, which did help with this discomfort. With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital. She was referred for rehabilitation and strengthening. Most of this was focused on her SI joints. At that time, although she had complained of foot discomfort, she was not treated for it. This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996. She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain. She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back. Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B. She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case. Subsequently, nuclear bone scans revealed osteoarthritis. Orthotics were provided. She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure. During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle. She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since. She currently does not have an established cardiologist having just changed insurance plans. She is establishing care with Dr. S, of Rheumatology for her ongoing care. Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis. A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation. She then transferred her care to Ab Cd, FNP under the direction of Dr. K. Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens. Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY: ,1. Attention deficit disorder.,2. TMJ arthropathy.,3. Migraines.,4. Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1. Cystectomies.,2. Sinuses.,3. Left ganglia of the head and subdermally in various locations.,4. TMJ and bruxism.,FAMILY HISTORY: ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1. Methadone 2.5 mg p.o. t.i.d.,2. Norco 10/325 mg p.o. q.i.d.,3. Tenormin 50 mg q.a.m.,4. Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5. Wellbutrin SR 100 mg q.d.,6. Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives. Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS: Blood pressure 110/72 with a pulse of 68.,HEENT: Normocephalic. Atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular motions are intact. No scleral icterus. No nystagmus. Tongue is midline. Mucous membranes are moist without exudate.,NECK: Free range of motion without thyromegaly.,CHEST: Clear to auscultation without wheeze or rhonchi.,HEART: Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN: Soft, nontender.,MUSCULOSKELETAL: There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally. Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side. Toe-heel walking is performed without difficulty. Straight leg raises are negative. Romberg's are negative.,NEUROLOGIC: Grossly intact. Intact reflexes in all extremities tested. Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review. I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.nan

PREOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,POSTOPERATIVE DIAGNOSES:,1. Status post multiple trauma/motor vehicle accident.,2. Acute respiratory failure.,3. Acute respiratory distress/ventilator asynchrony.,4. Hypoxemia.,5. Complete atelectasis of left lung.,6. Clots partially obstructing the endotracheal tube and completely obstructing the entire left main stem and entire left bronchial system.,PROCEDURE PERFORMED: ,Emergent fiberoptic plus bronchoscopy with lavage.,LOCATION OF PROCEDURE: ,ICU. Room #164.,ANESTHESIA/SEDATION:, Propofol drip, Brevital 75 mg, morphine 5 mg, and Versed 8 mg.,HISTORY,: The patient is a 44-year-old male who was admitted to ABCD Hospital on 09/04/03 status post MVA with multiple trauma and subsequently diagnosed with multiple spine fractures as well as bilateral pulmonary contusions, requiring ventilatory assistance. The patient was noted with acute respiratory distress on ventilator support with both ventilator asynchrony and progressive desaturation. Chest x-ray as noted above revealed complete atelectasis of the left lung. The patient was subsequently sedated and received one dose of paralytic as noted above followed by emergent fiberoptic flexible bronchoscopy.,PROCEDURE DETAIL,: A bronchoscope was inserted through the oroendotracheal tube, which was partially obstructed with blood clots. These were lavaged with several aliquots of normal saline until cleared. The bronchoscope required removal because the tissue/clots were obstructing the bronchoscope. The bronchoscope was reinserted on several occasions until cleared and advanced to the main carina. The endotracheal tube was noted to be in good position. The bronchoscope was advanced through the distal trachea. There was a white tissue completely obstructing the left main stem at the carina. The bronchoscope was advanced to this region and several aliquots of normal saline lavage were instilled and suctioned. Again this partially obstructed the bronchoscope requiring several times removing the bronchoscope to clear the lumen. The bronchoscope subsequently was advanced into the left mainstem and subsequently left upper and lower lobes. There was diffuse mucus impactions/tissue as well as intermittent clots. There was no evidence of any active bleeding noted. Bronchoscope was adjusted and the left lung lavaged until no evidence of any endobronchial obstruction is noted. Bronchoscope was then withdrawn to the main carina and advanced into the right bronchial system. There is no plugging or obstruction of the right bronchial system. The bronchoscope was then withdrawn to the main carina and slowly withdrawn as the position of endotracheal tube was verified, approximately 4 cm above the main carina. The bronchoscope was then completely withdrawn as the patient was maintained on ventilator support during and postprocedure. Throughout the procedure, pulse oximetry was greater than 95% throughout. There is no hemodynamic instability or variability noted during the procedure. Postprocedure chest x-ray is pending at this time.cardiovascular / pulmonary, multiple trauma, motor vehicle accident, acute respiratory failure, acute respiratory distress, ventilator asynchrony, hypoxemia, atelectasis, bronchoscopy, lavage, fiberoptic bronchoscopy, endotracheal tube, acute respiratory, asynchrony, bronchoscope, fiberoptic, endotracheal, bronchial, ventilatory, tube, respiratory,

S -, A 44-year-old, 250-pound male presents with extreme pain in his left heel. This is his chief complaint. He says that he has had this pain for about two weeks. He works on concrete floors. He says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking. He also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old. He also has redness and infection of the right toes.,O -, The patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face. He has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet. He has redness of the right toes 2, 3 and 4. Extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,A -, 1. Plantar fasciitis.,podiatry, plantar fasciitis, tinea pedis, tinea purpura, heel, fasciitis, plantar,

REASON FOR VISIT: ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS: ,Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. She had some physical therapy, which has been helping with the neck pain. The right hand weakness continues. She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction. No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:, Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS: ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress. Alert and oriented x3. Normocephalic and atraumatic. Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution. Biceps and brachioradialis reflexes are 3 plus. Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups. Patellar reflex is 3 plus. No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease. There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6. These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level. Minimal degenerative disk disease is seen at the C6-7. This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done. I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain. She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age. Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty. She understands.,She would like to proceed with the surgery, relatively soon. She has her birthday coming up on 07/20/07 and would like to hold off, until after then. Our tentative date for the surgery is 08/01/07. She will go ahead and continue the preoperative testing process.nan

PREOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1. Left facial cellulitis.,2. Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA: ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA. The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology. The patient states that this was started approximately 24 hours ago. The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain. The patient admits to poor dental hygiene. Denies any recent or dental abscesses in the past. The patient is a substance abuser, does admit to smoking cocaine approximately three days ago. The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted. After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE: ,The patient was brought in upright and supine position. Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side. This was done at the base of #18, #19, and #20 teeth. After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control. After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed. There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination. The patient understood consequences of her actions. Does state that she does not care at this time and just wants to be left alone. At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin. The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.surgery, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis,

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Cataract, right eye.,PROCEDURE:, Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:, None,SPECIMENS:, None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye. The patient had the risks and benefits of surgery discussed. After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed. Following this, the patient was sterilely prepped and draped in the usual fashion. After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis. Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision. Following this, the cystotome was used to make a continuous tear-type capsulotomy. After this, BSS was used to hydrodissect and hydrodelineate the lens. The phacoemulsification unit was used to remove the cataract. The I&A unit was used to remove the residual cortical material. Following this, Provisc was used to inflate the bag. The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed. Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight. The lid speculum was removed. Acular and Vigamox drops were placed. The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.ophthalmology, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular

FINDINGS:,High resolution computerized tomography was performed from T12-L1 to the S1 level with reformatted images in the sagittal and coronal planes and 3D reconstructions performed. COMPARISON: Previous MRI examination 10/13/2004.,There is minimal curvature of the lumbar spine convex to the left.,T12-L1, L1-2, L2-3: There is normal disc height with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints.,L3-4: There is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. Normal central canal and facet joints (image #255).,L4-5: There is normal disc height, circumferential annular disc bulging, left L5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (AP) contouring the rightward aspect of the thecal sac. Orthopedic hardware is noted posteriorly at the L5 level. Normal central canal, facet joints and intervertebral neural foramina (image #58).,L5-S1: There is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. The orthopedic hardware creates mild streak artifact which mildly degrades images. There is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of L5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left L5 nerve root. There is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,There is no bony destructive change noted.,There is no perivertebral soft tissue abnormality.,There is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,IMPRESSION:,Minimal curvature of the lumbar spine convex to the left.,L3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,L4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left L5 laminectomy.,L5-S1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left L5 nerve root with questionable neural impingement.,Minimal to mild arteriosclerotic vascular calcifications.neurology, posterior annular disc, circumferential annular disc, normal central canal, annular disc bulging, lumbar spine, posterior annular, facet joints, annular disc, disc bulging, tomography, disc, lumbar, orthopedic, postsurgical, spine, annular, bulging,

PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1. Flexible bronchoscopy.,2. Mediastinoscopy.,3. Right thoracotomy.,4. Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1. Radiation Oncology.,2. Pulmonary Medicine.,3. Medical Oncology.,4. Cancer Center Team consult.,5. Massage therapy consult.,HOSPITAL COURSE:, The patient's hospital course was unremarkable. Her pain was well controlled with an epidural that was placed by Anesthesia. At the time of discharge, the patient was ambulatory. She was discharged with home oxygen available. She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d. She was discharged with a prescription for Vicodin for pain control. She is to follow up with Dr. X in the office in one week with a chest x-ray. She is instructed not to lift, push or pull anything greater than 10 pounds. She is instructed not to drive until after she sees us in the office and is off her pain medications.discharge summary, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,

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

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

DIAGNOSIS AT ADMISSION:, Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1. Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2. Congestive heart failure.,3. Atherosclerotic cardiovascular disease.,4. Mild senile-type dementia.,5. Hypothyroidism.,6. Chronic oxygen dependent.,7. Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X. She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A. 600 mg b.i.d. She was placed on oral Levaquin after a load of 500 mg and 250 mg a day. She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1. Digoxin was 1.3. White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000. Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate. There is a question if there is mild fluid overload.,The patient improved with the above regimen. By discharge, her lungs fell back to her baseline. She had no significant shortness of breath. Her O2 saturations were stable. Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS: ,Guarded.discharge summary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,

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

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.general medicine, horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,

HISTORY OF PRESENT ILLNESS: ,The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months.,PAST MEDICAL HISTORY:,1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month.,3. He had an appendectomy in the 1940s.,4. He had an ankle resection in 1975.,SOCIAL HISTORY: ,The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.,FAMILY HISTORY: , There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.,CURRENT MEDICATIONS: , Fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., Cymbalta 30 mg p.o. per day, Prilosec 20 mg p.o. per day, Lortab 10 mg p.o. per day, Amoxil 500 mg p.o. per day, vitamin B12 1000 mcg weekly, vitamin D 1000 units per day, Metamucil p.r.n., enteric-coated aspirin once a day, Colace 200 mg p.o. q.d., Senokot three tablets p.o. p.r.n., Reglan 10 mg p.o. q.6h., Xanax 0.25 mg p.o. q.8h. p.r.n., Ambien 5 mg p.o. q.h.s. p.r.n. and Dilaudid 2 mg tablets p.o. q.3h. p.r.n., Protonix 40 mg per day, and Megace 400 mg per day.,ALLERGIES:, He has no medication or food allergies.,REVIEW OF SYSTEMS:, Please see the health questionnaire and clinical notes from today.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS: BP was 137/60, P was 89, and his weight could not be measured because he was in a wheelchair. His pain score was 0.,APPEARANCE: No acute distress. He is pleasant and well-groomed.,HEENT: Atraumatic, normocephalic. No carotid bruits appreciated.,LUNGS: There were few coarse crackles in both lung bases.,CARDIOVASCULAR: Revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs. The pulse was regular and of normal volume.,ABDOMEN: Soft with no masses and normal bowel sounds. There were no carotid bruits.,EXTREMITIES: No contractures appreciated.,NEUROLOGICAL EXAM:,MSE: His orientation, language, calculations, 100-7 tests were all normal. There was atrophy and fasciculations in both the arms and legs.,CRANIAL NERVES: Cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations. His palatal movement was normal and gag reflex was normal.,MOTOR: Strength was decreased in all muscle groups as follows: Deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4. Foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1. There was atrophy in both hands and general atrophy of the lower limb muscles. The feet were both cold and showed dystrophic features. Fasciculations were present mainly in the hands. There was evidence of dysmetria and past pointing in the left hand.,REFLEXES: Reflexes were 0 in all sites in the arms and legs. The jaw reflex was 2+. Vibration was severely decreased at the elbow and wrist and was absent in the fingers. Vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee. Joint position sense was absent in the toes and severely decreased in the fingers. Pin perception was absent in the feet and was decreased to the upper thighs. Pin was decreased or absent in the fingers and decreased above the elbows. The same distribution of sensory loss was found with monofilament testing.,COORDINATION: Coordination was barely normal in the right hand. Rapid alternating movements were decreased in the left hand greater than the right hand. The patient was unable to stand and therefore gait, Romberg's test and balance could not be assessed.,DIAGNOSTIC STUDIES: , Previous diagnostic studies and patient reports. There were extensive patient reports, all of which were reviewed. A previous x-ray study of the lateral chest performed in October 2008 showed poor inspiration with basilar atelectasis and an infiltrate. An x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis. A CTA of the neck with and without contrast performed in November 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis. The posterior circulation showed a slightly dominant right vertebral artery with no stenosis. There was no significant stenosis, but there was minor extracranial stenosis noted. An MRI of the brain with and without contrast performed in November 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration. There was also no significant sinusitis or mastoiditis. This was an essentially normal brain MRI. A CBC performed in January 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated MCH of 32.4 and the rest of the study was normal. An electrolyte study performed in January 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1. The glucose was 86. TSH performed in January 2009 was 1.57, which is within the normal range. Vitamin B12 was greater than a 1000, which is normal and the folate was 18.2, which was normal. A myocardial stress study performed in December 2008 showed normal myocardial perfusion with Persantine Cardiolite SPECT. The ECG was non-diagnostic. There was normal regional wall motion of the left ventricle. The left ventricular ejection fraction was 68%, which is within the normal range for males. A CT of the lumbar spine without contrast performed in December 2008 showed a broad-based disc bulge at L1-L2, L2-L3, L3-L4 and L4-L5. At L5-S1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis. There was severe bilateral neural foraminal stenosis at L5-S1 and moderate neural foraminal stenosis at L1-L4. An echocardiogram was performed in November 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,DIAGNOSTIC IMPRESSION: ,The patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings. He is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities. His proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia. According to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since July 2008. As indicated below, further diagnostic studies including a detailed nerve conduction and EMG test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy. There was no involvement of the tongue on EMG. The laboratory testing as indicated below failed to show a specific cause for the neuropathy. We are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the Mayo Clinic. This type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as SLE, Sjogren's, rheumatoid arthritis, and mixed connective tissue disease. In addition, it may also be seen with certain toxins, particularly chemotherapeutic agents. The patient did not receive any of these. It may also be seen as part of a paraneoplastic syndrome. Although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking. We have requested that he obtain a CT of his chest, abdomen and pelvis while he is in Acute Rehabilitation. The verbal reports of these possibly did not show any evidence of a cancer. We did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm. The patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm. This showed evidence of severe axonal loss. There was no evidence of a vasculitis. The vessels did show some mild intimal changes that would be consistent with atherosclerosis. There were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections. The muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping. Again, there was no evidence of inflammation or vasculitis. Evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy. Specifically, there is no history of HIV exposure. We would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis. At this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed. I have discussed these issues at length with the patient and with his son. We also addressed whether or not there might be a previously undiagnosed inherited neuropathy. I think this is unlikely given the short history and the rapid progression of the disorder.,There is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as Charcot-Marie-Tooth disease type 2. However, since I have only seen the patient on one occasion and do not know what his previous examination showed two years ago, I cannot be certain that there may not have been the presence of a neuropathy preceding this.,PLAN:,1. Nerve conduction and EMG will be performed today. The results were indicated above.,2. The following laboratory studies were requested including electrolytes, CBC, thyroid function tests, B12, ANA, C-reactive protein, complement, cryoglobulins, double-stranded DNA antibodies, folate level, hemoglobin A1c, immunofixation electrophoresis, P-ANCA, C-ANCA, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the Mayo Clinic, B12. These studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7. The B12 was greater than 2000. The immunoelectrophoresis, ANA, double-stranded DNA, ANCA, hemoglobin A1c, folate, cryoglobulins, complement, C-reactive protein were all normal or negative. The B12 level was greater than 2000. Liver function tests were normal. The glucose was 90. ESR was 10. Hemoglobin A1c was 5.5.,3. A left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4. CT of chest, abdomen and pelvis.,5. Whole body gallium scan for evidence of an underlying neoplasm.,6. The patient will go to the Rehabilitation Facility for Acute Rehabilitation and Training.,7. We have not made any changes to his medication. He does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day. Usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8. Followup will be as determined by the family.nan

LEXISCAN MYOVIEW STRESS STUDY,REASON FOR THE EXAM: , Chest discomfort.,INTERPRETATION: , The patient exercised according to the Lexiscan study, received a total of 0.4 mg of Lexiscan IV injection. At peak hyperemic effect, 24.9 mCi of Myoview were injected for the stress imaging and earlier 8.2 mCi were injected for the resting and the usual SPECT and gated SPECT protocol was followed and the data was analyzed using Cedars-Sinai software. The patient did not walk because of prior history of inability to exercise long enough on treadmill.,The resting heart rate was 57 with the resting blood pressure 143/94. Maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,EKG at rest showed sinus rhythm with no significant ST-T wave changes of reversible ischemia or injury. Subtle nonspecific in III and aVF were seen. Maximum stress test EKG showed inverted T wave from V4 to V6. Normal response to Lexiscan.,CONCLUSION: ,Maximal Lexiscan perfusion with subtle abnormalities non-conclusive. Please refer to the Myoview interpretation.,MYOVIEW INTERPRETATION: , The left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51. EF estimated and calculated at 56%.,Cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,IMPRESSION:,1. Normal stress/rest cardiac perfusion with no indication of ischemia.,2. Normal LV function and low likelihood of significant epicardial coronary narrowing.,radiology, chest discomfort, lexiscan myoview stress study, mci, spect, gated spect, myoview, lexiscan, stress test, ekg, lexiscan myoview, lv function, coronary narrowing, heart rate, blood pressure, myoview interpretation, cardiac perfusion, cardiac, ischemia, perfusion, stress,

PREOPERATIVE DIAGNOSIS: , Ovarian cancer.,POSTOPERATIVE DIAGNOSIS:, Ovarian cancer.,OPERATION PERFORMED:, Insertion of a Port-A-Catheter via the left subclavian vein approach under fluoroscopic guidance.,DETAILED OPERATIVE NOTE:, The patient was placed on the operating table and placed under LMA general anesthesia in preparation for insertion of a Port-A-Catheter. The chest was prepped and draped in the routine fashion for insertion of a Port-A-Catheter. The left subclavian vein was punctured with a single stick and a guidewire threaded through the needle into the superior vena cava under fluoroscopic guidance. The needle was removed. An incision was made over the guidewire for entrance of the dilator with sheath. A second counter incision was made transversally on the chest wall about an inch and half below the puncture site with a #15 blade. Hemostasis was effective to electrocautery, and a pocket was fashioned subcutaneously for positioning of the reservoir. The Port-A-Catheter reservoir tubing was attached to the reservoir in the routine fashion. The reservoir was placed in the pocket and sutured to the anterior chest wall muscle with three interrupted 4-0 Prolene sutures for stability. Next, a catheter passer was passed from the pocket exiting through the skin at the puncture site, previously placed for the guidewire, and the Port-A-Catheter was pulled from the reservoir exiting on the skin. It was placed on the chest, measured, and cut to the appropriate length. This having been done, the dilator with sheath attached was passed over the guidewire into the superior vena cava under fluoroscopic guidance. The guidewire and dilator were removed, and the Port-A-Catheter was threaded through the sheath into the superior vena cava, and the sheath removed under fluoroscopic guidance. Fluoroscopy revealed the Port-A-Catheter to be in excellent position. The Port-A-Catheter was accessed with a butterfly 90-degree needle percutaneously that drew blood well and flushed easily. It was flushed with heparinized saline connected in cath. This having been done, the puncture site was closed with a circumferential subcutaneous 3-0 Vicryl suture, and the skin was closed with a percutaneous circumferential subcuticular suture. This having been done, attention was applied to the reservoir incision. It was closed with two layers of continuous 3-0 Vicryl suture, and the skin was closed with a continuous 3-0 Monocryl subcuticular stitch. A dry sterile dressing was applied, and the patient having tolerated the procedure was transferred to the recovery room for postoperative care.surgery, ovarian cancer, insertion, port-a-catheter, circumferential, counter incision, fluoroscopic, fluoroscopic guidance, guidewire, subclavian, superior vena cava, port a catheter, port, catheter, subcutaneously, vein

CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES: ,Penicillin.,REVIEW OF SYSTEMS: ,The patient's chief complaint is her weight. She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key. She has questions as to whether or not there would be any contra indications to her going on the diet. Otherwise, she feels great. She had family reunion in Iowa once in four days out there. She continues to volunteer Hospital and is walking and enjoying her summer. She denies any fevers, chills, or night sweats. She has some mild constipation problem but has had under control. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,

TITLE OF OPERATION:, Mediastinal exploration and delayed primary chest closure.,INDICATION FOR SURGERY:, The patient is a 12-day-old infant who has undergone a modified stage I Norwood procedure with a Sano modification. The patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass. The patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago. She did not meet the criteria for delayed primary chest closure.,PREOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,POSTOP DIAGNOSIS: , Open chest status post modified stage I Norwood procedure.,ANESTHESIA:, General endotracheal.,COMPLICATIONS:, None.,FINDINGS: , No evidence of intramediastinal purulence or hematoma. At completion of the procedure no major changes in hemodynamic performance.,DETAILS OF THE PROCEDURE: , After obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position. Following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed. The chest was then prepped and draped in the usual sterile fashion and previously placed segmental AlloDerm was removed. The mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned. Through a separate incision and another 15-French Blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the RV-PA connection as well as inferior most aspect of the ventriculotomy. The pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires. The subcutaneous tissue and skin were closed in layers. There was no evidence of significant increase in central venous pressure or desaturation. The patient tolerated the procedure well. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was transferred to the Pediatric Intensive Care Unit shortly thereafter in critical but stable condition.,I was the surgical attending present in the operating room in charge of the surgical procedure throughout the entire length of the case.surgery, mediastinal exploration, delayed primary chest closure, extracorporeal membrane oxygenation, stage i norwood procedure, sano modification, chest closure, infant, mediastinal, exploration, closure, endotracheal, chest

PROCEDURE:, Total hip replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, the patient was turned on the side and secured in the hip table. An incision was made, centered over the greater trochanter. Dissection was sharply carried down through the subcutaneous tissues. The gluteus maximus was incised and split proximally. The piriformis and external rotators were identified. These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule. The hip was dislocated. A femoral neck cut was made using the guidance of preoperative templating. The femoral head was removed. Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken. The femur was retracted anteriorly and a complete labrectomy was performed. Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas. The trial shell was placed and found to have an excellent fit. The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction. Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw. Excellent purchase was obtained. The trial liner was placed.,The femur was then flexed and internally rotated. The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion. An intramedullary hole was drilled into the femur to define the canal. Reaming was performed until the appropriate size was reached. The broaches were then used to prepare the femur with the appropriate amount of version. Once the appropriate size broach was reached, it was used as a trial with head and neck placement. Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation. The hip was found to have excellent stability with the final chosen head-neck combination. Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position. The real head was impacted atop the stem. If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version. Excess cement was removed from the edges of the component. Range of motion and stability were once again checked and found to be excellent. Adequate hemostasis was obtained. Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy. The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was closed with nylon. Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur

PREOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic renal failure.,2. Uremia.,PROCEDURE PERFORMED: ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia. The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time. He is slightly short of breath with mild difficulty in breathing. A pre-procedure x-ray was obtained, which showed no pneumothorax. He did have a significant right pleural effusion and a mild left pleural effusion. We decided to insert the catheter on the right side.,PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion. 1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein. Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return. The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return. The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty. The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used. The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty. The guidewire was removed. Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty. The ports were flushed with injectable normal saline secondary to the patient going for dialysis today. Thus, he will not need heparinization of the lines. Again, he tolerated the procedure well. A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications.surgery, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia,

PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:, Under general anesthesia with an endotracheal tube, the patient was placed in supine position. A mouth gag was inserted and suspended from Mayo stand. Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate. The adenoid area was inspected. The adenoids were small. The left tonsil was grasped with a tonsil tenaculum. The tonsil was removed with the Gold laser. The apposite tonsil was removed in a similar manner. Hemostasis was secured with electrocautery. Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline. The patient tolerated the procedure well and left the operating room in good condition.ent - otolaryngology, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy

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.office notes, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 34-year-old white female who is a nurse in the operating room. She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her. She is very bright and well informed about cosmetic surgery. She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this. Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation. Her breasts are reportedly healthy without any significant problems. Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: , Negative. Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06. She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:, Significant for Huntington disease in her mother and diabetes in her father. Her brother has an aneurysm. She does occasionally smoke and has been trying to quit recently. She is currently smoking about a pack a day. She drinks about once a week. She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins. She has no children.,REVIEW OF SYSTEMS: ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region. She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain. She has considered difficult airway due to anterior cervical disk fusion and instability. Her last mammogram was in 2000. She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone. She is tanned. Her lower abdomen has some excess adiposity. There is some mild laxity of the lower abdominal skin. Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation. There was no piercing in that region. Her breasts are C shaped. They are not ptotic. They have good symmetry with no evidence of tubular breast deformity. She has no masses or lesions noted. The nipples are of appropriate size and shape for a woman of her age. Her scar on her neck from her anterior cervical disk fusion is well healed. Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia. I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely. This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option. I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible. I think her lower abdominal skin is of good tone. I think suction lipectomy in this region would bring down her size and accentuate her waist nicely. I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck. I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed. I will try to set this up in the near future. I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure. Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.cosmetic / plastic surgery, breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,

PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: ,Minimal.,TOTAL TOURNIQUET TIME: ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed. A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws. There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed. There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS: ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall. The patient noted while walking with a walker, apparently tripped and fell. The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room. At that time, a closed reduction was performed and she was placed in a Robert-Jones splint. After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE: ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained. The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia. The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position. At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation. All bony prominences were well padded at this time. A nonsterile tourniquet was placed on the right upper thigh of the patient. This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes. Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle. A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures. Once the bone was reached, the fractured site was identified. The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site. The wound was copiously irrigated and dried. Next, the fracture was then reduced in anatomic position. There was noted to be quite a bit of comminution as well as soft overall status of the bone. It was held in place with reduction forceps. A six hole one-third tubular Synthes plate was then selected for instrumentation. It was contoured using ________ and placed on the lateral aspect of the distal fibula. Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each. The most proximal was a 12 mm and the next two were 16 mm in length. Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole. The most distal with a 20 mm and two most proximal were 18 mm in length. Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position. There was no lateralization of the joints. Attention was then directed towards the medial aspect of the ankle. Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus. Again, the dissection was carefully taken down the level of the fracture site. The retractors were then placed to protect all neurovascular structures. Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum. The fracture site was then displaced and the ankle joint was visualized including the dome of the talus. There appeared to be some minor degenerative changes of the talus, but no loose bodies. Next, the wound was copiously irrigated and suctioned dry. The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire. Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length. These appeared to hold the fracture site securely in an anatomic position. Again, Xi-scan was brought in to confirm placement of the screws. They were in good overall position and there was no lateralization of the joint. At this time, each wound was copiously irrigated and suctioned dry. The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin. A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril. A Robert-Jones style splint was then placed on the right lower extremity. This was covered by a 4-inch Depuy dressing. At this time, the Department of Anesthesia reversed the sedation. The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit. The patient tolerated the procedure well. There were no complications.surgery, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus,

PROCEDURE PERFORMED: , Bassini inguinal herniorrhaphy.,ANESTHESIA: , Local with MAC anesthesia.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. The patient was sedated and an adequate local anesthetic was administered using 1% lidocaine without epinephrine. The patient was prepped and draped in the usual sterile manner.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Care was taken not to injure the ilioinguinal nerve. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures. The sac was dissected free from the cord structures using a combination of blunt dissection and Bovie electrocautery.,Once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature. The sac was excised and sent to Pathology. The stump was examined and no bleeding was noted. The ends of the suture were then cut, and the stump retracted back into the abdomen.,The floor of the inguinal canal was then strengthened by suturing the shelving edge of Poupart's ligament to the conjoined tendon using a 2-0 Prolene, starting at the pubic tubercle and running towards the internal ring. In this manner, an internal ring was created that admitted just the tip of my smallest finger.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior and superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.urology, ilioinguinal nerve, adherent cremasteric muscle, bassini inguinal herniorrhaphy, external oblique aponeurosis, inguinal herniorrhaphy, metzenbaum scissors, external ring, blunt dissection, cord structures, bovie electrocautery, inguinal, electrocautery

PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:, None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.ophthalmology, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular

PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:, Bilateral chronic otitis media,ANESTHESIA:, General mask,NAME OF OPERATION:, Bilateral Myringotomy with placement of PE tubes,PROCEDURE:, The patient was taken to the operating room and placed in the supine position. After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case. First, the left and then the right tympanic membrane, was approached. An anterior-inferior radial incision was made in the left tympanic membrane. Suction revealed a substantial amount of mucopurulent drainage. A Sheehy pressure equalization tube was placed in the myringotomy site. Floxin drops were added. The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.surgery, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes,

HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.,PAST MEDICAL HISTORY, FAMILY HISTORY, SOCIAL HISTORY & REVIEW OF SYSTEMS:, See Patient History sheet, which was reviewed with the patient and is signed in the chart. Past medical history on the patient, past surgical history, current medications, drug-related allergies and social history have all been updated and reviewed, and enclosed in the chart.,PHYSICAL EXAMINATION: , Physical exam reveals a pleasant, 57-year-old female who is 5 feet 4 inches and 150 pounds. She has palpable pulses. Neurologic sensation is intact. Examination of the extremities shows the patient as having well-healed surgical sites from her arthroplasty, second digits bilaterally and prior bunionectomy. There is a recurrence of bunion deformity noted on both great toes although the patient notes to have reasonably good range of movement. She has particular pain in the second MTP joint of the right foot and demonstrates a mild claw-toe deformity of the second and third toes to the left foot, and to a lesser degree the second toe to the right. Gait analysis: The patient stands and walks with a rather severe pes planus and has generalized hypermobility noted in the feet.,X-RAY INTERPRETATION:, X-rays taken today; three views to the right foot shows presence of internal K-wire and wire from prior bunionectomy. Biomechanical analysis shows 15 degree intermetatarsal angle and approximately 45 degree hallux abducto valgus angle. No evidence of arthrosis in the joint is noted. Significant shift to the fibular sesamoid is present.,ASSESSMENT:,1. Recurrent bunion deformity, right forefoot.,2. Pes planovalgus deformity, bilateral feet.,PLAN/TREATMENT:,1. Today, we did review remaining treatment options with the patient including the feasibility of conservative versus surgical treatment. The patient would require an open wedge osteotomy to reduce the intermetatarsal angle with the lateral release and a decompression osteotomy at the second metatarsal. Anticipated length of healing was noted for the patient as were potential risks and complications. The patient ultimately would probably require surgery on her left foot at a later date as well.,2. The patient will explore her ability to get out of work for the above-mentioned period of time and will be in touch with regards regarding scheduling at a later date.,3. All questions were answered.consult - history and phy., x-rays, pain, mtp joint, pes planovalgus deformity, pes planovalgus, bunion deformity, planovalgus, forefoot, foot, deformity, bunionectomy, bunion

PREOPERATIVE DIAGNOSIS:, Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1. Dural tear, postoperative laminectomy, L4-L5.,2. Laterolisthesis, L4-L5.,3. Spinal instability, L4-L5.,OPERATIONS PERFORMED,1. Complete laminectomy, L4.,2. Complete laminectomy plus facetectomy, L3-L4 level.,3. A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4. Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5. Posterior spinal fusion, L4 to S1.,6. Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS: ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago. He presented several days later with headaches as well as a draining wound. He was subsequently taken back for a dural repair. For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines. He has fullness in the back of his wound. The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak. The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:, After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7. The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties. The patient was given intraoperative antibiotics. The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level. Full-thickness skin flaps were developed. It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid. Cultures were taken, aerobic, anaerobic, AFB, fungal. Once this was done, the paraspinal muscles were affected from the posterior elements. It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1. It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis. Once this was done; however, the fluid emanating from the dura could not be seen appropriately. Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left. Complete laminectomy at L3 was done. Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen. Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture. A Valsalva confirmed no significant lead after the repair was made. There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation. The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl. After this the standard starting point was made. Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall. Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall. The screws were subsequently placed. Tricortical purchase was obtained at S1 ________ appropriate size screws. Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1. This was done on the right side first. The screw was torqued at S1 appropriately and subsequently at L5. Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4. Neutral compression distraction was obtained on the left side. Screws were torqued at L4, L5, and S1 appropriately. Good placement was seen both in AP and lateral planes using fluoroscopy. Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette. Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix. This was placed in the posterior lateral gutters. DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately. Deep retractors then removed from the confines of the wound. Fascia was closed using interrupted Prolene running suture #1. Once this was done, suprafascial drain was placed appropriately. Subcutaneous tissues were opposed using a 2-0 Prolene suture. The dermal edges were approximated using staples. Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape. The drain was connected appropriately. The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition. No complications arose.

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.general medicine, 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

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY: ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties. The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1. To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2. He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3. We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4. To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1. The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2. The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.speech - language, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis

CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glans penis. Next, incision line was marked circumferentially on the outer skin 3 mm below the corona. The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia. Next, the foreskin was retracted. Another circumferential incision was made 3 mm proximal to the corona. The intervening foreskin was excised. Meticulous hemostasis was obtained with electrocautery. Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock. The stitches were placed equal distance among these to reapproximate all the skin edges. Next, good cosmetic result was noted with no bleeding at the end of the procedure. Vaseline gauze, Telfa, and Elastoplast dressing was applied. The stay-stitch was removed and pressure held until bleeding stopped. The patient tolerated the procedure well and was returned to the recovery room in stable condition.urology, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: 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: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition.gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,

REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant. Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction. The urinary bladder is normal. The uterus appears unremarkable. Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen. The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.nephrology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including use of gowns, mask, and gloves, etc. The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:, Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin. A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened. Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery. There was good venous blood return on the first try. Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm. It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact. There was good blood return from both lumens, which were flushed with heparinized saline. The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:, Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:, Attention was directed to the left wrist, which was placed on wrist rest. The Allen test was normal. A Cook 2.5-French 5 cm long arterial catheter kit was opened. A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return. Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact. There was pulsatile blood return and the catheter was flushed with heparinized saline solution. It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure. The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure. There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion. Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance. There was good visualization of the heart. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. The probe was removed at the end. There was no trauma and there was no blood tingeing.,surgery, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter

CHIEF COMPLAINT:, "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No recent illness. No fever or chills. HEENT: No headache. No neck pain. No vision change or hearing change. No eye or ear pain. No rhinorrhea. No sore throat. CARDIOVASCULAR: No chest pain. No palpitations or racing heart. RESPIRATIONS: No shortness of breath. No cough. GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then. The patient denies any abdominal pain. No change in bowel movements. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No dizziness, syncope, or near syncope. PSYCHIATRIC: The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations. ENDOCRINE: No heat or cold intolerance.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes. The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal. CONSTITUTIONAL: The patient is well nourished, and well developed, appears to be healthy. The patient is calm and comfortable, in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctiva bilaterally. The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally. No evidence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Nose is normal without rhinorrhea or audible congestion. Ears are normal without any sign of infection. Mouth and oropharynx are normal without any signs of infection. Mucous membranes are moist. NECK: Supple and nontender. Full range of motion. There is no JVD. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub or gallop. Peripheral pulses are +3 and bounding. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. No wheezes, rales or rhonchi. Good air movement bilaterally. GASTROINTESTINAL: Abdomen is soft, nontender, normal and benign. MUSCULOSKELETAL: No abnormalities noted in back, arms, or legs. The patient is normal use of her extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact in all extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. The patient does not have any smell of alcohol and does not exhibit any clinical intoxication. The patient is quite pleasant, fully cooperative. HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted. No bruising is noted.,DIAGNOSES:,1. ECSTASY INGESTION.,2. ALCOHOL INGESTION.,3. VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:, I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation. The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal. The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.consult - history and phy., nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy,

DATE OF ADMISSION:, MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:, X Y, M.D.,ADMITTING DIAGNOSES:,1. Ewing sarcoma.,2. Anemia.,3. Hypertension.,4. Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION: ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity. She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY. A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation. MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction. CT showed similar result. The patient received her first cycle of chemotherapy on MM/DD/YYYY. On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy. She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1. Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2. She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.general medicine, iron deficiency anemia, hypertension and obesity, iron deficiency, urine, anemia, hypertension, chemotherapy, discharge, ewing, sarcoma,

PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1. Intrauterine pregnancy at 33 weeks, twin gestation.,2. Active preterm labor.,3. Advanced dilation.,4. Multiparity.,5. Requested sterilization.,6. Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7. Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:, Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section. The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm. The decision for C-section was made.,PROCEDURE:, The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision. The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors. The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically. The abdominal rectus muscle was divided in the center and extended in a vertical fashion. Peritoneum was entered at a high point and extended in a vertical fashion as well. The bladder blade was put in place. The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally. The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus. The first fetus was vertex. The fluid was clear. The head was delivered followed by the remaining portion of the body. The cord was doubly clamped and cut. The newborn handed off to waiting pediatrician and nursery personnel. The second fluid was ruptured. It was the clear fluid as well. The presenting part was brought down to be vertex. The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel. Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology. At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection. Then, there were multiple omental adhesions on the surface of the uterus itself. This needed to be released as well as on the abdominal wall and then the uterus could be externalized. The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first. The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath. The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized. The same technique was completed on the left side with the knuckle portion cut off and cauterized as well. The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis. Interceed was placed over this area as well. The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position. The gutters were wiped clean of any remaining blood. The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges. The abdominal rectus muscle was irrigated. The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue. Skin edges were re-approximated with sterile staples. Sterile dressing was applied. Uterus was evacuated of any remaining blood vaginally. The patient was taken to the recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct.obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,

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

XYZ,RE: ABC,MEDICAL RECORD#: 123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today. He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion. The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent. It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective. Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen. They came in with a list of eight possible agents that they would like to be administered within the next two weeks. They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him. This is very worrisome. Today, for the first time, I felt that there was a definite right facial droop as well. Therefore, there is no doubt that he is becoming symptomatic from his growing tumor. It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation. Despite an hour, this again amazingly was not possible. It is not that he does not want treatment, however. Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen. We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days. In addition, we will stop thalidomide 100 mg/day. If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us. At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval. In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later. I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups. If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma

REASON FOR THE CONSULT:, Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer. There is a concern that the patient had a low-grade fever of 100.2 early this morning. The patient otherwise feels well. He was not even aware of the fever. He does have some ankle pain, worse on the right than the left. Old medical records were reviewed. He has multiple hospitalizations for leg cellulitis. Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past. Klebsiella and Enterobacter have also grown in the few wound cultures at some point. The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No malaise. Positive recent low-grade fevers. No chills.,HEENT: No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion. No sore throat.,CARDIAC: No chest pain or cough.,GASTROINTESTINAL: No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY: ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago. He is also a former cigarette smoker, quit several years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS:, Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE: The patient is awake, alert, and not in cardiorespiratory distress. Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES: Pink conjunctivae, anicteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No thrills or rubs.,GASTROINTESTINAL: Normoactive bowel sounds. Soft. No guarding or rigidity.,LYMPHATIC: No cervical lymphadenopathy.,MUSCULOSKELETAL: Good range of motion of upper and lower extremities.,SKIN: There is hyperpigmentation involving the distal calf of both legs. There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage. Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg. There is warmth, but minimal tenderness on palpation of this area. There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm. Wound edges are poorly defined.,PSYCHIATRIC: Appropriate mood and affect, oriented x3. Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000. BUN and creatinine 9.2/0.52. Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6. One wound culture from right leg wound culture from 01/27/09 noted with young growth. Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:, Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus. No absolute findings.,IMPRESSION:,1. Fevers.,2. Right leg/ankle cellulitis.,3. Chronic recurrent bilateral ankle venous ulcers.,4. Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5. Hypertension.,RECOMMENDATIONS:,1. We have ordered 2 sets of blood cultures.,2. Agree with daptomycin and Primaxin IV.,3. Follow up result of wound cultures.,4. I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup.nan

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

PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition.gastroenterology, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder

PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:, In preoperative identification, the patient was taken to the operating room and placed in supine position. Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. Table was turned. The right shoulder roll was placed. The head was turned to the left and rested on a doughnut. The scalp was shaved, and then prepped and draped in usual sterile fashion. Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. The parietal boss incision was opened. It was about an inch and a half in length. It was carried down to the skull. Self-retaining retractor was placed. A bur hole was now fashioned with the perforator. This was widened with a 2-mm Kerrison punch. The dura was now coagulated with bipolar electrocautery. It was opened in a cruciate-type fashion. The dural edges were coagulated back to the bony edges. There was egress of a large amount of liquid. Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. It was secured with a 3-0 nylon suture. The area was closed with interrupted inverted 2-0 Vicryl sutures. The skin was closed with staples. Sterile dressing was applied. The patient was subsequently returned back to anesthesia. He was extubated in the operating room, and transported to PACU in satisfactory condition.surgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space