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T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation.

Consult - History and Phy.

Cancer of the nasopharynx

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.

Dietary consultation for carbohydrate counting for type I diabetes.

Consult - History and Phy.

Carbohydrate Counting

SUBJECTIVE:, This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. She gave herself, in smaller increments, a total of 70 extra units of her Humalog. Ten of those units were injectable; the others were in the forms of pump. Her blood sugar was over 600 when she went to the hospital later that day. She is here at this consultation complaining of not feeling well still because she has a cold. She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:, Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours. A diet history was obtained. I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. The Lilly guide for meal planning was provided and reviewed. Additional carbohydrate counting book was provided.,ASSESSMENT:, The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. It is based on the 500 rule which suggests this ratio. We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. She does seem to have a pattern of fixing blood sugars later in the day after they are elevated. We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately. The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:, Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. This was a one-hour consultation. Provided my name and number should additional needs arise.

The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff, presents to the hospital with abdominal pain, cramping, and persistent diarrhea.

Consult - History and Phy.

C. Diff Colitis Consult

REASON FOR CONSULT: ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea. After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin. She was also placed on IV Reglan because of nausea and vomiting. In spite of the above, her white count still continues to be elevated today. On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X. Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY: ,Noncontributory.,SOCIAL HISTORY: ,No history of smoking, alcohol, or drug use. She lives at home.,HOME MEDICATIONS: ,She is on atenolol and Mevacor.,ALLERGIES: NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS: ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness. She denies any cough, sputum production, or dysuria at this time. Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL: She is awake and alert, currently in no apparent distress.,VITAL SIGNS: She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT: Pupils are round and reactive to light and accommodation.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: S1 and S2 are present. No rales appreciated.,ABDOMEN: She does have tenderness to palpation all over with some mild rebound tenderness also. No guarding noted. Bowel sounds present.,EXTREMITIES: No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89. UA on 6/18/2009 showed no evidence of UTI. Sodium today 130, potassium 2.7, and creatinine 0.4. AST and ALT on 6/20/2009 were normal. Blood cultures from admission were negative. Urine culture on admission was negative. C. diff was positive. Stool culture was negative.,ASSESSMENT:,1. A 72-year-old female with Clostridium difficile colitis.,2. Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3. Leukocytosis secondary to above, mild improvement today though.,4. Bilateral pleural effusion by CT of the chest, although could represent thickening.,5. New requirement for oxygen, rule out pneumonia.,6. Hypertension.,PLAN:,1. Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2. Continue p.o. vancomycin. Add Florastor to help replenish the gut flora.,3. Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4. We will check a chest x-ray especially given her new requirement for oxygen.

First-degree and second-degree burns, right arm secondary to hot oil spill - Workers' Compensation industrial injury.

Consult - History and Phy.

Burn - Consult

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY: ,Noncontributory.,MEDICATIONS: ,None.,ALLERGIES: ,None.,PHYSICAL EXAMINATION: , GENERAL: Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. His only injury is to the right upper extremity. There are first and second degree burns on the right forearm, ranging from the elbow to the wrist. Second degree areas with blistering are scattered through the medial aspect of the forearm. There is no circumferential burn, and I see no areas of deeper burn. The patient moves his hands well. Pulses are good. Circulation to the hand is fine.,FINAL DIAGNOSIS:,1. First-degree and second-degree burns, right arm secondary to hot oil spill.,2. Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution. The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication. A burn dressing is applied with Neosporin ointment. The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. He is to return tomorrow for a dressing change. Tetanus immunization is up to date. Preprinted instructions are given. Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.

Suspicious calcifications upper outer quadrant, left breast. Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

Consult - History and Phy.

Breast Calcifications - Preop Consult

REASON FOR HOSPITALIZATION: ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08. That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position. Additional imaging studies confirmed the suspicious nature of these calcifications. The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08. The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis. No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast. She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy. I was called to see the patient in the emergency consultation in the breast center. At the same time, Dr. Y was consulted in Interventional Radiology. Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material. This resulted in immediate occlusion of the false aneurysm. The patient was seen in my office for followup appointment on 06/24/08. At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy. There was, however, no evidence of reforming of the false aneurysm. There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband. The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings. For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization. Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months. The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04. This revealed benign histologic findings. The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40. Other than her age, the patient has no other risk factors for development of breast cancer. She is not receiving any hormone replacement therapy. She has had five children with the first pregnancy occurring at the age of 24. Other than her daughter, there are no other family members with breast cancer. There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1. Plavix.,2. Arava.,3. Nexium.,4. Fosamax.,5. Advair.,6. Singulair.,7. Spiriva.,8. Lexapro.,DRUG ALLERGIES:, ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke. She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS: ,The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly aged female who is alert and in no distress.,HEENT: Head, normocephalic. Eyes, PERRL. Sclerae are clear. Mouth, no oral lesions.,NECK: Supple without adenopathy.,HEART: Regular sinus rhythm.,CHEST: Fair air entry bilaterally. No wheezes are noted on examination.,BREASTS: Normal topography bilaterally. There are no palpable abnormalities in either breast mound. Nipple areolar complexes are normal. Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses. The previous tissue changes from the stereotactic core needle biopsy have resolved. Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN: Obese. No masses. Normal bowel sounds are present.,BACK: No CVA tenderness.,EXTREMITIES: No clubbing, cyanosis or edema.,ASSESSMENT:,1. Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2. Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3. History of chronic obstructive lung disease and asthma, controlled with medications.,4. History of gastroesophageal reflux disease, controlled with medications.,5. History of transient ischemic attack managed with medications.,6. History of osteopenia and osteoporosis, controlled with medications.,7. History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography. This will be performed on an outpatient basis.

The patient was admitted for symptoms that sounded like postictal state. CT showed edema and slight midline shift. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.

Consult - History and Phy.

Brain Tumor - Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in regard to his likely recurrent brain tumor.,HISTORY OF PRESENT ILLNESS: , The patient was admitted for symptoms that sounded like postictal state. He was initially taken to Hospital. CT showed edema and slight midline shift, and therefore he was transferred here. He has been seen by Hospitalists Service. He has not had a recurrent seizure. Electroencephalogram shows slowing. MRI of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery. There is inhomogeneous uptake consistent with potential necrosis. He also has had a SPECT image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm. The patient was diagnosed with a brain tumor in 1999. All details are still not available to us. He underwent a biopsy by Dr. Y. One of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at Clinic. That is not available on the chart as I dictate.,After discussion of treatment issues with radiation therapist and Dr. Z (medical oncologist), the decision was made to treat him primarily with radiation alone. He tolerated that reasonably well. His wife says it's been several years since he had a scan. His behavior had not been changed, until it changed as noted earlier in this summary.,PAST MEDICAL HISTORY: , He has had a lumbar fusion. I believe he's had heart disease. Mental status changes are either due to the tumor or other psychiatric problems.,SOCIAL HISTORY:, He is living with his wife, next door to one of his children. He has been disabled since 2001, due to the back problems.,REVIEW OF SYSTEMS: , No headaches or vision issues. Ongoing heart problems, without complaints. No weakness, numbness or tingling, except that related to his chronic neck pain. No history of endocrine problems. He has nocturia and urinary frequency.,PHYSICAL EXAMINATION: , Blood pressure 146/91, pulse 76. Normal conjunctivae. Ears, nose, throat normal. Neck is supple. Chest clear. Heart tones normal. Abdomen soft. Positive bowel sounds. No hepatosplenomegaly. No adenopathy in the neck, supraclavicular or axillary regions. Neurologically alert. Cranial nerves are intact. Strength is 5/5 throughout.,LABORATORY WORK: , White blood count 10.4, hemoglobin 16, platelets not noted. Sodium 137, calcium 9.1.,IMPRESSION AND PLAN:, Likely recurrent low-grade tumor, possibly evolved to a higher grade, given the MRI and SPECT findings. Dr. X's note suggests discussing the situation in the tumor board on Wednesday. He is stable enough. The pause in his care would not jeopardize his current status. It would be helpful to get old films and pathology from Abbott Northwestern. However, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis. Optimizing his treatment would probably be helped by knowing his current grade of tumor.

Breast reconstruction post mastectomy. A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.

Consult - History and Phy.

Breast Reconstruction

REASON FOR CONSULTATION:, Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year. She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer. This apparently was positive in two separate locations within the suspicious area. She also underwent MRI, which suggested that there was significant size to the area involved. Her contralateral left breast appeared to be uninvolved. She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications. She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight. Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps. There are no any significant scars on the right breast as she has only undergone needle biopsy at this point. Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:, A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction. We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction. I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim. A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy. I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration. I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure. We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant. In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery. Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed. In any case, she does prefer this option in order to avoid the need for an implant. We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen. We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction. At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy. For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days. We may cancel this if the chance of postoperative irradiation is high. If this is the case, I think we can do a better job on the reconstruction if we defer it. The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.

Evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet - recurrent bunion deformity, right forefoot & pes planovalgus deformity, bilateral feet.

Consult - History and Phy.

Bunion & Pes Planovalgus Deformity

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.

Blood in toilet. Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

Consult - History and Phy.

Blood In Toilet

CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.

Patient with a history of gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall.

Consult - History and Phy.

Bladder Cancer

CHIEF COMPLAINT: , Bladder cancer.,HISTORY OF PRESENT ILLNESS:, The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y.,PAST MEDICAL HISTORY: , Includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease.,PAST SURGICAL HISTORY:, Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure.,CURRENT MEDICATIONS:,1. Metoprolol 100 mg b.i.d.,2. Diltiazem 120 mg daily.,3. Hydrocodone 10/500 mg p.r.n.,4. Pravastatin 40 mg daily.,5. Lisinopril 20 mg daily.,6. Hydrochlorothiazide 25 mg daily.,FAMILY HISTORY: , Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history.,SOCIAL HISTORY: , The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner.,PHYSICAL EXAMINATION:,GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: The penis is circumcised and there are no lesions, plaques, masses or deformities. There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection.,LABORATORY EXAM:, Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,IMPRESSION:, Bladder cancer.,PLAN: ,The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley or penis at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan.

Hypomastia. Patient wants breast augmentation and liposuction of her abdomen,

Consult - History and Phy.

Breast Augmentation Consult

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.

Modified Barium swallow study evaluation to objectively evaluate swallowing function and safety. The patient complained of globus sensation high in her throat particularly with solid foods and with pills. She denied history of coughing and chocking with meals.

Consult - History and Phy.

Barium Swallow Study Evaluation

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

The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.

Consult - History and Phy.

Barium Swallow Study Evaluation - 1

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

Bladder instillation for chronic interstitial cystitis.

Consult - History and Phy.

Bladder Instillation

CHIEF COMPLAINT:, The patient comes for bladder instillation for chronic interstitial cystitis.,SUBJECTIVE:, The patient is crying today when she arrives in the office saying that she has a lot of discomfort. These bladder instillations do not seem to be helping her. She feels anxious and worried. She does not think she can take any more pain. She is debating whether or not to go back to Dr. XYZ and ask for the nerve block or some treatment modality to stop the pain because she just cannot function on a daily basis and care for her children unless she gets something done about this, and she fears these bladder instillations because they do not seem to help. They seem to be intensifying her pain. She has the extra burden of each time she comes needing to have pain medication one way or another, thus then we would not allow her to drive under the influence of the pain medicine. So, she has to have somebody come with her and that is kind of troublesome to her. We discussed this at length. I did suggest that it was completely appropriate for her to decide. She will terminate these if they are that uncomfortable and do not seem to be giving her any relief, although I did tell her that occasionally people do have discomfort with them and then after the completion of the instillations, they do better and we have also had some people who have had to terminate the instillations because they were too uncomfortable and they could not stand it and they went on to have some other treatment modality. She had Hysterectomy in the past.,MEDICATIONS: , Premarin 1.25 mg daily, Elmiron 100 mg t.i.d., Elavil 50 mg at bedtime, OxyContin 10 mg three tablets three times a day, Toprol XL 25 mg daily.,ALLERGIES:, Compazine and Allegra.,OBJECTIVE:,Vital Signs: Weight: 140 pounds. Blood pressure: 132/90. Pulse: 102. Respirations: 18. Age: 27.,PLAN:, We discussed going for another evaluation by Dr. XYZ and seeking his opinion. She said that she called him on the phone the other day and told him how miserable she was and he told her that he really thought she needed to complete. The instillations give that a full trial and then he would be willing to see her back. As we discussed these options and she was encouraged to think it over and decide what she would like to do for I could not makeup her mind for her. She said she thought that it was unreasonable to quit now when she only had two or three more treatments to go, but she did indicate that the holiday weekend coming made her fearful and if she was uncomfortable after today’s instillation which she did choose to take then she would choose to cancel Friday’s appointment, also that she would not feel too badly over the holiday weekend. I thought that was reasonable and agreed that that would work out.,PROCEDURE:,: She was then given 10 mg of morphine subcutaneously because she did not feel she could tolerate the discomfort in the instillation without pain medicine. We waited about 20 minutes. The bladder was then instilled and the urethra was instilled with lidocaine gel which she tolerated and then after a 10-minute wait, the bladder was instilled with DMSO, Kenalog, heparin, and sodium bicarbonate, and the catheter was removed. The patient retained the solution for one hour, changing position every 15 minutes and then voided to empty the bladder. She seemed to tolerate it moderately well. She is to call and let me know what she wishes to do about the Friday scheduled bladder instillation if she tolerated this then she is going to consider trying it. If not, she will cancel and will start over next week or she will see Dr. Friesen.

A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The pain is located laterally as well as anteriorly into the groin.

Consult - History and Phy.

Bilateral Hip Pain

HISTORY OF PRESENT ILLNESS: ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration. The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.,PAST MEDICAL HISTORY: ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES: ,The patient has no known drug allergies.,SOCIAL HISTORY: ,The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression. The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:, X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:, After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 4

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

The patient was referred for an outpatient speech and language pathology consult to increase speech and swallowing abilities. The patient is currently NPO with G-tube to meet all of his hydration and nutritional needs. A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing.

Consult - History and Phy.

Barium Swallow Study & Speech Evaluation

CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS: ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1. Completion of modified barium swallow study.,2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. The patient will increase laryngeal elevation by 50% for airway protection.,4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1. The patient will improve secretion management to tolerable levels.,2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve.

The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior. Bipolar affective disorder, manic state. Rule out depression.

Consult - History and Phy.

Bipolar Affective Disorder - Consult

IDENTIFYING DATA: ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT: ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior. Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband. She then turned on the oven and put her head in the oven and then tried to climb over the second storied balcony. All of these behaviors were interrupted by her husband who called 911. He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS: ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked. After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium. Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit. The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital. She arrives here and is today pacing on the unit and in and out of the large TV room area. She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner. She is highly tangential, delusional, and disorganized. She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY: ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009. Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present. She is currently treated by Dr. Y. She has been involuntarily detained at least 7 times and revoked at least 6 times. She was on XYZ Inpatient in 2001 and in 01/2009. She states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY: ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o. AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard. She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc. Of note, she also has a history of abusing Vicodin.,ALLERGIES: ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband. There are no children. She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin. The X Hospital tox screen of last night was positive for opiates. Her lithium level per last night at X Hospital was 0.42 mEq/L. She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:, Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:, None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH: ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid. Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT: ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital. Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:, Nil. When asked, are there situations when you lose control, she refuses to answer. When asked, are meds helpful, she refuses to answer. She refuses to give her family information nor release of information to contact them.,ASSETS:, The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:, The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,: The patient has bipolar affective disorder in a manic state at present. She also may be depressed and is struggling with marital issues.,DIAGNOSES:

Consult - History and Phy.

Barium Swallow Study & Speech Evaluation - 1

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heartburn and/or gastroesophageal reflux disorder. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC. The patient was seated upright in a video imaging chair throughout this assessment. To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:, Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid. Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation. Penetration was noted with cup sips of thin liquid only. Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies. The patient's hyolaryngeal elevation and anterior movement are within functional limits. Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus. Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:, No aspiration was noted during this evaluation. Penetration with cup sips of thin liquid. The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1. The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2. The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3. The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.

Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.

Consult - History and Phy.

Bariatric Consult - Surgical Weight Loss - 2

PAST MEDICAL HISTORY: ,She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:, Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:, She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.

A 74-year-old woman for Cardiology consultation regarding atrial fibrillation and anticoagulation after a fall. The patient denies any chest pain nor clear shortness of breath.

Consult - History and Phy.

Atrial Fibrillation - Consult

HISTORY OF PRESENT ILLNESS:, I was kindly asked to see Ms. ABC who is a 74-year-old woman for cardiology consultation regarding atrial fibrillation and anticoagulation after a fall.,The patient is somnolent at this time, but does arouse, but is unable to provide much history. By review of the chart, it appears that she fell, which is what she states when she got up out of a rocking chair and could not get herself off the floor. She states that 1-1/2 hours later she was able to get herself off the floor.,The patient denies any chest pain nor clear shortness of breath.,PAST MEDICAL HISTORY: , Includes, end-stage renal disease from hypertension. She follows up with Dr. X in her office and has been known to have a small-to-moderate sized pericardial effusion since 11/07 that has apparently been followed and it appears that the patient was not interested in having diagnostic pericardiocentesis done. She had an echocardiogram today (please see also that report), which shows stable and small-to-moderate sized pericardial effusion without tamponade, normal left ventricular ejection fraction at 55% with mild concentric left ventricular hypertrophy, mildly dilated right ventricular size, normal right ventricular ejection fraction, moderate mitral regurgitation and severe tricuspid regurgitation with severe pulmonary hypertension, estimated PA systolic pressure of 71 mmHg when compared to the prior echocardiogram done 08/29/07, previously the mitral regurgitation was mild and previously the PA systolic pressure was estimated at 90 mmHg. Other findings were not significantly changed including pericardial effusion description. She has a history of longstanding hypertension. She has been on hemodialysis since 1997 for renal failure, history of mini-strokes documented several years ago, history of seizure disorder, she has a history of right upper extremity edema and right breast enlargement from right subclavian vein occlusion. She has a history of hypertension, depression, hyperlipidemia, on Sensipar for tertiary hyperparathyroidism.,PAST SURGICAL HISTORY: , Includes, cholecystectomy, post fistula in the left arm, which has failed, and right arm, which is being used including number of operative procedures to the fistula. She follows up with Dr. Y regarding neurovascular surgery.,MEDICATIONS: , On admission:,1. Norvasc 10 mg once a day.,2. Aspirin 81 mg once a day.,3. Colace 200 mg two at bedtime.,4. Labetalol 100 mg p.o. b.i.d.,5. Nephro-Vite one tablet p.o. q.a.m.,6. Dilantin 100 mg p.o. t.i.d.,7. Renagel 1600 mg p.o. t.i.d.,8. Sensipar 120 mg p.o. every day.,9. Sertraline 100 mg p.o. nightly.,10. Zocor 20 mg p.o. nightly.,ALLERGIES: , TO MEDICATIONS PER CHART ARE NONE.,FAMILY HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,SOCIAL HISTORY: ,Unable to obtain as the patient becomes quite sleepy when I am talking.,REVIEW OF SYSTEMS: , Unable to obtain as the patient becomes quite sleepy when I am talking.,PHYSICAL EXAM: ,Temperature 99.2, blood pressure ranges from 88/41 to 108/60, pulse 70, respiratory rate, 20, O2 saturation 98%. Height is 5 feet 1 inch, weight 147 pounds. On general exam, she is a pleasant elderly woman who does arouse to voice, but then becomes quite sleepy and apparently that is an improvement from when she was admitted. HEENT shows the cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins are difficult to assess, but do not appear clinically distended. No carotid bruits. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2 regular rate, 3/6 holosystolic murmur heard with radiation from the left apex towards the left axilla. No rub, no gallop. PMI is nondisplaced. Abdomen: Soft, nondistended. CVA is benign. Extremities with no significant edema. Pulses appear grossly intact. She has evidence of right upper extremity edema, which is apparently chronic.,DIAGNOSTIC DATA/LAB DATA: , EKGs are reviewed including from 07/07/09 at 08:31 a.m., which shows atrial fibrillation with left anterior fascicular block, poor R-wave progression when compared to one done on 07/06/09 at 18:25, there is really no significant change. The atrial fibrillation appears present since at least on EKG done on 11/02/07 and this EKG is not significantly changed from the most recent one. Echocardiogram results as above. Chest x-ray shows mild pulmonary vascular congestion. BNP shows 3788. Sodium 136, potassium 4.5, chloride 94, bicarbonate 23, BUN 49, creatinine 5.90. Troponin was 0.40 followed by 0.34. INR 1.03 on 05/18/07. White blood cell count 9.4, hematocrit 42, platelet count 139.,IMPRESSION: , Ms. ABC is a 74-year-old woman admitted to the hospital with a fall and she has a history of vascular dementia, so her history is somewhat unreliable it seems and she is somnolent at that time. She does have chronic atrial fibrillation again documented at least present since 2007 and I found an EKG report by Dr. X, which shows atrial fibrillation on 08/29/07 per her report. One of the questions we were asked was whether the patient would be a candidate for Coumadin. Clearly given her history of small mini-strokes, I think Coumadin would be appropriate given this chronic atrial fibrillation, but the main issue is the fall risk. If not felt to be significant fall risk then I would strongly recommend Coumadin as the patient herself states that she has only fallen twice in the past year. I would defer that decision to Dr. Z and Dr. XY who know the patient well and it may be that physical therapy consult is appropriate to help adjudicate.,RECOMMENDATIONS:,1. Fall assessment as per Dr. Z and Dr. XY with possible PT consult if felt appropriate and if the patient is not felt to be at significant fall risk, would put her on Coumadin. Given her history of small strokes as documented in the chart and her chronic atrial fibrillation, she does have reasonable heart rate control on current labetalol.,2. The patient has elevated BNP and I suspect that is due to her severe pulmonary hypertension and renal failure and in the light of normal LV function, I would not make any further evaluation of that other than aggressive diuresis.,3. Regarding this minimal troponin elevation, I do not feel this is a diagnosis especially in the setting of pulmonary hypertension and her small-to-moderate sized stable pericardial effusion again that has been longstanding since 2007 from what I can tell and there is no evidence of tamponade. I would defer to her usual cardiologist Dr. X whether an outpatient stress evaluation is appropriate for risk stratification. I did find that the patient had a prior cardiac stress test in 08/07 where they felt that there was some subtle reversibility of the anterior wall, but it was felt that it may be artifact rather than true ischemia with normal LV function seen on that study as well.,4. Continue Norvasc for history of hypertension as well as labetalol.,5. The patient is felt to be a significant fall risk and will at least continue her aspirin 81 mg once a day for secondary CVA, thromboprophylaxis (albeit understanding that it is inferior to Coumadin).,6. Continue Dilantin for history of seizures.

The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother.

Consult - History and Phy.

Attempted Suicide - Consult

IDENTIFYING DATA: , The patient is a 21-year-old Caucasian male, who attempted suicide by trying to jump from a moving car, which was being driven by his mother. Additionally, he totaled his own car earlier in the day, both of which occurrences occurred approximately 72 hours before arriving at ABCD Hospital. He says he had a "panic attack leading to the car wreck" and denies that any of his behavior was suicidal in nature responding, "I was just trying to scare my mother.",CHIEF COMPLAINT: , The patient does say, "I screwed up my whole life and wrecked my car." The patient claims he is med compliant, although his mother, and stepfather saying he is off his meds. He had a two-day stay at XYZ Hospital for medical clearance after his car accident, and no injuries were found other than a sore back, which was negative by x-ray and CT scan.,PRESENT ILLNESS: ,The patient is on a 72-your involuntary hold for danger to self and grave disability. He has a history of bipolar disorder with mania and depression with anxiety and panic attacks. Today, he went to involuntary court hearing and was released by the court. He is now being discharged from second floor ABCD Psychiatric Hospital.,PAST PSYCHIATRIC HISTORY:, Listed extensively in his admission note and will not be repeated.,MEDICAL HISTORY: , Includes migraine headaches and a history of concussion. He describes "allergy" to Haldol medication.,OUTPATIENT CARE: , The patient sees a private psychiatrist, Dr. X. Followup with Dr. X is arranged in four days' time and the patient is discharged with four days of medication. This information is known to Dr. X.,DISCHARGE MEDICATIONS:,The patient is discharged with:,1. Klonopin 1 mg t.i.d. p.r.n.,2. Extended-release lithium 450 mg b.i.d.,3. Depakote 1000 mg b.i.d.,4. Seroquel 1000 mg per day.,SOCIAL HISTORY: ,The patient lives with his girlfriend on an on-and-off basis and is unclear if they will be immediately moving back in together.,SUBSTANCE ABUSE: , The patient was actively tox screen positive for benzodiazepines, cocaine, and marijuana. The patient had an inpatient stay in 2008 at ABC Lodge for drug abuse treatment.,MENTAL STATUS EXAM:, Notable for lack of primary psychotic symptoms, some agitation, and psychomotor hyperactivity, uncooperative behavior regarding his need for ongoing acute psychiatric treatment and stabilization. There is an underlying hostile oppositional message in his communications.,FORMULATION: , The patient is a 21-year-old male with a history of bipolar disorder, anxiety, polysubstance abuse, and in addition ADHD. His recent behavior is may be at least in part associated with active polysubstance abuse and also appears to be a result of noncompliance with meds.,DIAGNOSES:,AXIS I:,1. Bipolar disorder.,2. Major depression with anxiety and panic attacks.,3. Polysubstance abuse, benzodiazepines, and others street meds.,4. ADHD.,AXIS II: , Deferred at present, but consider personality disorder traits.,AXIS III:, History of migraine headaches and past history of concussion.,AXIS IV: , Stressors are moderate.,AXIS V: , GAF is 40.,PLAN: , The patient is released from the hospital secondary to court evaluation, which did not extend his involuntary stay. He has an appointment in four days with his outpatient psychiatrist, Dr. X. He has four days' worth of medications and agrees to no self-harm or harm of others. Additionally, he agrees to let staff know or authorities know if he becomes acutely unsafe. His mother and stepfather have been informed of the patient's discharge and the followup plan.

Patient complaining of cough and blood mixed with sputum production with a past medical history significant for asbestos exposure.

Consult - History and Phy.

Asbestos Exposure - Hemoptysis

REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure. The patient also has a very extensive cardiac history that would be outlined below. He is being admitted with worsening shortness of breath and constipation. He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1. Benign prostatic hypertrophy.,2. Peptic ulcer disease.,3. Atrial fibrillation.,4. Coronary artery disease.,5. Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6. ICD implantation.,7. Peripheral vascular disease.,8. CABG in 1991 and 1998.,9. Congestive heart failure, EF 40%.,10. Asbestos exposure.,MEDICATIONS,1. Coumadin 6 mg alternating with 9 mg.,2. Prevacid 30 mg once a day.,3. Diovan 160 mg every day.,4. Flomax 0.4 mg every day.,5. Coreg 25 mg in the morning and 12.5 mg at night.,6. Aldactone 25 mg a day.,7. Lasix 20 mg a day.,8. Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL: The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS: Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT: Significant for peripheral cyanosis.,NECK: Supple.,LUNGS: Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR: Regular rate and rhythm with murmur and metallic click.,ABDOMEN: Soft and benign.,EXTREMITIES: 1+ cyanosis. No clubbing. No edema.,LABORATORY DATA:, Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000. CK 266, PTT 37, PT 34, and INR 3.7. Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1. Hemoptysis.,2. Acute bronchitis.,3. Coagulopathy.,4. Asbestos exposure.,5. Left pleural effusion.,RECOMMENDATIONS,1. Antibiotics.

Questionable need for antibiotic therapy for possible lower extremity cellulitis.

Consult - History and Phy.

Antibiotic Therapy Consult

REASON FOR CONSULTATION: , Questionable need for antibiotic therapy for possible lower extremity cellulitis.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema. She follows up at the wound care center at Hospital. Her lower extremity edema is being managed there. She has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral Bactrim and ciprofloxacin in the past according to her. As her lymphedema was not improving on therapy at that facility, she was referred for admission to Long-Term Acute Care Facility for lymphedema management. She at present has a stage II ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas. Her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,I have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,PAST MEDICAL HISTORY:, Positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities. She has had a hysterectomy and a cholecystectomy in the remote past.,SOCIAL HISTORY: , The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.,FAMILY HISTORY: , Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.,ALLERGIES: , ADHESIVE TAPE ALLERGIES.,REVIEW OF SYSTEMS:, At present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left. She denies any nausea, vomiting or diarrhea. She denies any pain, tenderness, increased warmth or drainage from the lower extremities. Denies chest pain, cough or phlegm production. All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General: A 51-year-old morbidly obese Caucasian female who is not in any acute hemodynamic distress at present.,Vital signs: Her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, I do not see a recorded weight at present.,HEENT: Pupils are equal, round, and reactive to light. Extraocular movements intact. Head is normocephalic and external ear exam is normal.,Neck: Supple. There is no palpable lymphadenopathy.,Cardiovascular system: Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop. Heart sounds are little distant secondary to thick chest wall.,Lungs: Clear to auscultation and percussion bilaterally.,Abdomen: Morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus. There is no evidence of cutaneous candidiasis in the inguinal folds. There is no palpable lymphadenopathy in the inguinal and femoral areas.,Extremities: Bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis. There is no increased warmth or tenderness, there is no skin breakdown except a stage II chronic ulcer on the lower medial aspect of the right calf area. It has minimal serosanguineous drainage and there is no surrounding erythema. Therefore, in my opinion, there is no current evidence of cellulitis or wound infection. There is no cyanosis or clubbing. There is no peripheral stigmata of endocarditis.,Central nervous system: The patient is alert and oriented x3, cranial nerves II through XII are intact, and there is no focal deficit appreciated.,LABORATORY DATA: , White cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils. The basic electrolyte panel is within normal limits and the renal function is normal with BUN of 17 and creatinine of 0.5. Liver function tests are also within normal limits.,The nasal screen for MRSA is negative. Urine culture is negative so far from admission. Urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,IMPRESSION AND PLAN:, A 51-year-old Caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema. Admitted for inpatient management of bilateral lower extremity lymphedema. I have been consulted to rule out possibility of active cellulitis and wound infection.,At present, I do not find evidence of active cellulitis that needs antibiotic therapy. In my opinion, lymphedema wraps could be initiated. We will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week. If she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,Her stage II ulcer on the right leg does not look infected. I would recommend continuation of wound care along with lymphedema wraps.,Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization. Dr. Y from Plastic Surgery and Lymphedema Management Clinic is following.,I appreciate the opportunity of participating in this patient's care. If you have any questions, please feel free to call me at any time. I will continue to follow the patient along with you 2-3 times per week during this hospitalization at the Long-Term Acute Care Facility.

The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.

Consult - History and Phy.

Atrial Fibrillation Management

REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation. The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam. EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation. The patient states that for the last 3 years, she has had episodes of her heart racing. It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. They subsequently resolve on their own and do not limit her in anyway. However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. She said she can walk no more than 25 feet without becoming tired. She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills. She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Myocardial infarction in 2003.,3. Left heart catheterization at University Hospital.,4. Hypercholesterolemia.,5. Arthritis.,6. CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1. Left total knee replacement in 2002.,2. Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer. There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years. She retired 7 years ago because of low back pain. She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1. Coumadin 5 mg a day.,2. Toprol-XL 50 mg a day.,3. Aspirin 81 mg a day.,4. Hydrochlorothiazide 25 mg a day.,5. Plendil 10 mg daily.,6. Lipitor 40 mg daily.,REVIEW OF SYSTEMS: ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. GENERAL: A well-developed, well-nourished, middle-aged African American female in no acute distress. NECK: Supple. No JVD. No carotid bruits. CARDIOVASCULAR: Irregularly irregular rate and rhythm. Normal S1 and S2. No murmurs, gallops or rubs. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Bowel sounds positive, soft, nontender, and nondistended. No masses. EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION: ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1. Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2. We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3. We will check a thyroid function panel.,4. We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5. Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6. Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. We will await results of transthoracic echocardiogram.,7. We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period. She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.

Possible exposure to ant bait. She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

Consult - History and Phy.

Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:, This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative. Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile. Stable vital signs and normal pulse oximetry. GENERAL: The child is very active, cheerful youngster, in no distress whatsoever. HEENT: Unremarkable. Oral mucosa is clear, moist, and well hydrated. I do not see any evidence of any sort of liquid on the face. Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso. Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:, I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely. She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation. So, the patient is discharged in stable condition.

The patient was running and twisted her right ankle - right ankle sprain.

Consult - History and Phy.

Ankle Pain - Consult

IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:, The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:, Otherwise negative except as stated above.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:, None.,SOCIAL HISTORY: , Mother appears loving and caring. There is no evidence of abuse.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , General: The patient is alert and oriented x4 in mild distress without diaphoresis. She is nonlethargic and nontoxic. Vitals: Within normal limits. The right ankle shows no significant swelling. There is no ecchymosis. There is no significant tenderness to palpation. The ankle has good range of motion. The foot is nontender. Vascular: +2/2 dorsalis pedis pulse. All compartments are soft. Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:, The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain. She may need to see a specialist, but at this time this is a very mild ankle injury. There is no significant physical finding, and I foresee no complications. I will give her 1 week off of PE.,MORBIDITY/MORTALITY:, I expect no acute complications. A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:, Moderate. The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:, Right ankle sprain.,PLAN:, Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.

Patient experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.

Consult - History and Phy.

Arm Pain - Neuro Consult

HISTORY OF PRESENT ILLNESS: ,The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.,He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,PAST MEDICAL HISTORY: , He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.,CURRENT MEDICATIONS: , He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams.,ALLERGIES:, He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy.,FAMILY HISTORY:, His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.,SOCIAL HISTORY:, He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.,REVIEW OF SYSTEMS: , He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: HR 72. RR 16.,General Appearance: Patient is well appearing, in no acute distress.,Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,NEUROLOGICAL EXAMINATION:,Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.,Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.,Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal.,RADIOLOGIC DATA:, MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis.,IMPRESSION: ,The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications.,RECOMMENDATIONS:,1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.,2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.,3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations.

Patient had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin.

Consult - History and Phy.

Angina - Consult

HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status.

History and Physical for right ankle sprain

Consult - History and Phy.

Ankle Sprain - H&P

CHIEF COMPLAINT:, Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK: Supple. No lymphadenopathy. No thyromegaly.,CHEST: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs.,ABDOMEN: Non-distended, nontender, normal active bowel sounds.,EXTREMITIES: No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending., ,IMPRESSION:, Right ankle sprain.,PLAN:,1. Motrin 800 mg t.i.d.,2. Tylenol 1 gm q.i.d. as needed.,3. Walking cast is prescribed.,4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills.

Refractory anemia that is transfusion dependent. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

Consult - History and Phy.

Anemia - Consult

DIAGNOSIS:, Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY: ,Diabetes.,PAST SURGICAL HISTORY:, Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him.,FAMILY HISTORY:, Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately.,VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds.,HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear.,NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES: No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC: Noncontributory.,DERMATOLOGIC: Noncontributory.,CARDIOVASCULAR: Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS: ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient.

Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.

Consult - History and Phy.

Allergy Evaluation Consult

HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:, History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:, PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,IMPRESSION: ,1. Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2. Renal failure requiring dialysis.,3. Hypertension.,RECOMMENDATIONS: ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow. If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions. At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy. Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions. An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen.

Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

Consult - History and Phy.

Annual Health Maintenance Exam

HISTORY OF PRESENT ILLNESS: ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health. Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker. His mother is 88, living and well, status post lung cancer resection. Two brothers, living and well. One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:, The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:, Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. Normal sinus rhythm. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. There are mild hemorrhoids in the anal canal. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.,IMPRESSION:,1. Comprehensive annual health maintenance examination.,2. Dyslipidemia.,3. Tinnitus, left ear.,4. Hemorrhoids.,PLAN:, At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Followup fasting lipid profile and ALT in 6 months.

Possible free air under the diaphragm. 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. No intra-abdominal pathology.

Consult - History and Phy.

Air Under Diaphragm - Consult

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.

The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.

Consult - History and Phy.

Airway Compromise & Foreign Body - ER Visit

HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES: ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION: ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. If not she would require tracheostomy. The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week.

The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus. Mild gait impairment and mild cognitive slowing.

Consult - History and Phy.

Adult Hydrocephalus

REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X. She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY: ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. She has been on Ambien, which is no longer been helpful. She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries.,SOCIAL HISTORY: ,She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,: Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS: Blood pressure 154/72, heart rate 87, and weight 153 pounds. Pain is 0/10.,HEAD: Head is normocephalic and atraumatic. Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE: Spine is straight and nontender. Spinous processes are easily palpable. She has very mild kyphosis, but no scoliosis.,SKIN: There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM: Regular rate and rhythm. No carotid bruits. No edema. No murmur. Peripheral pulses are good. Lungs are clear.,MENTAL STATUS: Assessed for recent and remote memory, attention span, concentration, and fund of knowledge. She scored 30/30 on the MMSE when attention was tested with either spelling or calculations. She had no difficulty with visual structures.,CRANIAL NERVES: Pupils are equal. Extraocular movements are intact. Face is symmetric. Tongue and palate are midline. Jaw muscles strong. Cough is normal. SCM and shrug 5 and 5. Visual fields intact.,MOTOR EXAM: Normal for bulk, strength, and tone. There was no drift or tremor.,SENSORY EXAM: Intact for pinprick and proprioception.,COORDINATION: Normal for finger-to-nose.,REFLEXES: Are 2+ throughout.,GAIT: Assessed using the Tinetti assessment tool. She was fairly quick, but had some unsteadiness and a widened base. She did not need an assistive device. I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008. It shows mild ventriculomegaly with a trace expansion into the temporal horns. The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. The sylvian aqueduct is patent. There is no pulsation artifact. Her corpus callosum is bowed and effaced. She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT: ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1. Possible adult hydrocephalus (331.5).,2. Mild gait impairment (781.2).,3. Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus. At this point, her symptoms are fairly mild. I explained to them the two methods of testing with CSF drainage. It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test. About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery. This procedure carries a 2% to 3% risk of meningitis. I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.

Acute episode of agitation. She was complaining that she felt she might have been poisoned at her care facility.

Consult - History and Phy.

Agitation - ER Visit

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

A 12-year-old fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.

Consult - History and Phy.

Abrasions & Lacerations - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago. There was loss of consciousness. The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:, None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:, None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES: ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single. He is a student. He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL: The patient denies weight loss/gain, fever, chills.,ENMT: The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV: The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY: The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI: The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU: The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS: The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO: The patient had a loss of consciousness during the accident. He does not recall the details of the accident. Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH: Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY: Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL: Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. The patient shows moderate obesity.,NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click or rub. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 3+ bilaterally, without audible bruits. Extremities show no edema or varicosities.,GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae.,LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL: Normal gait and station. The patient is on a stretcher. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN: There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. No induration or subcutaneous nodules to palpation.,NEUROLOGIC: Normal sensation by touch. The patient moves all four extremities.,PSYCHIATRIC: Oriented to time, place, and person. Appropriate mood and affect.,LABORATORY DATA: Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1. Concussion.,2. Facial abrasion.,3. Scalp laceration.,4. Knee abrasions.,PLANS/RECOMMENDATIONS:, Admitted for observation.

Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

Consult - History and Phy.

Acne Vulgaris - H&P

CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.,Menses: Onset: 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:, Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:, Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:, No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:, Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:, Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:, Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal. Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities. Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis. Face shows keratotic papule.,IMPRESSION:, Acne vulgaris.,PLAN:, Recommended treatment is antibiotic therapy. Patient received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:, Patient received literature regarding acne vulgaris. Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:, Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes

Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

Consult - History and Phy.

Admission History & Physical - Nausea

CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS: ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY: ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol. He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS: ,Otherwise negative.,PHYSICAL EXAMINATION:, His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically.,STUDIES:, His white blood cell count is 8.4 with 79 segs. His hematocrit is 41. His electrolytes are normal. His bilirubin is 2.8. His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.

The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

Consult - History and Phy.

Acute Cystitis & Diabetes Type II

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

Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. The patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion.

Consult - History and Phy.

Abnormal Echocardiogram

REASON FOR CONSULTATION: ,Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency.,HISTORY OF PRESENT ILLNESS: ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, the patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: ,Nonsignificant.,PAST SURGICAL HISTORY: , No major surgery.,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation.,ALLERGIES: ,AMBIEN, CARDIZEM, AND IBUPROFEN.,PERSONAL HISTORY:, She is a nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY: ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur.,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness.,HEENT: History of cataract, blurred vision, and hearing impairment.,CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease.,RESPIRATORY: Shortness of breath. No pneumonia or valley fever.,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena.,UROLOGICAL: No frequency or urgency.,MUSCULOSKELETAL: Arthritis and severe muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA or CVA. No seizure disorder.,ENDOCRINE/HEMATOLOGICAL: As above.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.,HEENT/NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated.,LUNGS: Air entry bilaterally fair. No obvious rales or wheezes.,HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN: Soft and nontender.,EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis.,DIAGNOSTIC DATA: , EKG: Normal sinus rhythm. No acute ST-T changes.,Echocardiogram report was reviewed.,LABORATORY DATA:, H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290.,IMPRESSION:,1. The patient admitted for gastrointestinal pathology, under working treatment.,2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation.,RECOMMENDATIONS:,1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.,2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.,3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function.

Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

Consult - History and Phy.

Acute Inferior Myocardial Infarction

CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea & 3 episodes of vomiting tonight. He denies any fever or chills. He admits prior episodes of similar pain prior to his PTCA in 1995. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:, All other systems reviewed & are negative.,PAST MEDICAL HISTORY:, Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs. Smokes 2 packs of cigarettes per day. Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay. Humulin N. insulin 50 units in a.m. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General: The patient is moderately obese but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person place and circumstance. There is no evidence of respiratory distress. The patient ambulates

A 5-month-old boy brought by his parents because of 2 days of cough.

Consult - History and Phy.

A 5-month-old boy with cough

CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.,REVIEW OF SYSTEMS:, No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:, He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said.,PAST MEDICAL HISTORY:, No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.,GENERAL: In no acute distress.,HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.,NECK: Supple.,NOSE: Dry secretions.,EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.,MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.,CHEST: Bilateral audible breath sound. No wheezes. No palpitation.,HEART: Regular rate and rhythm with no murmur.,ABDOMEN: Soft, nontender, and nondistended.,GENITOURINARY: Tanner I male with descended testes.,EXTREMITIES: Capillary refill less than 2 seconds.,LABS:, White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:, A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,

Work restrictions and disability evaluation

Chiropractic

Permanent & Stationary Report

PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently. She is having difficulty with bending and stooping maneuvers. She cannot lift heavy objects. She states she continues to have pain in her right neck and pain in her right upper extremity. She has difficulty with pushing and pulling and lifting with her right arm. She describes an intermittent tingling sensation in the volar aspect of her right hand. She states she has diminished grip strength in her right hand because of wrist pain complaints. She states that the Wellbutrin samples I had given her previously for depression seem to be helping. Her affect appears appropriate. She reports no suicidal ideation. She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints. She also takes Imitrex occasionally for headache complaints related to her neck pain. She also takes Flexeril occasionally for back spasms and Darvocet for pain. She is asking for a refill on some of her medications today. She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile. Blood pressure is 106/68, pulse of 64, respirations of 20. Her physical exam is unchanged from 03/21/05. Her orthopedic exam reveals full range of motion of the cervical spine. Cervical compression test is negative. Valsalva's maneuver is negative. Hoffmann's sign is negative. DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally. Her sensation is grossly intact to the upper extremity dermatomes. Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists. Passive range of motion of the right wrist is painful for her. Passive range of motion of the left wrist is non painful. Active range of motion of both wrists and hands are full. She is right hand dominant. Circumferential measurements were taken in her upper extremities. She is 11" in the right biceps, 10 1/2" in the left biceps. She is 9 3/4" in both right and left forearms. Circumferential measurements were also taken of the lower extremities. She is 21" at both the right and left thighs, 15" in both the right and left calves. Jamar dynamometry was assessed on three tries in this right-hand-dominant individual. She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand. , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor. Lumbar extension is to 30 degrees. The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh. The left SLR is to 90 degrees without back pain. DTRs are +1 at the knees and ankles. Toes are downgoing to plantar reflexes bilaterally. Sensation is grossly intact in the lower extremity dermatomes. Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1) Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2) Cervical sprain/strain with myofascial dysfunction. (3) Thoracic sprain/strain with myofascial dysfunction. (4) Probable chronic tendonitis of the right wrist. She has negative nerve conduction studies of the right upper extremity. (5) Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory. I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:, I told the patient to continue her medication course per above. It seems to be helping with some of her pain complaints. I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms. I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04. , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager. She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground. She had onset of headaches and neck pain, and pain complaints about her right upper extremity. She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain. , ,FACTORS FOR DISABILITY:,OBJECTIVE: ,1. She exhibits decreased range of motion in the lumbar trunk.,2. She has an abnormal MRI revealing a disc herniation at L5-S1.,3. She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1. Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2. With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3. Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4. Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds. She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain. She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates. She also relates headaches, which she did not have prior to her industrial injury. , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient. It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort. The patient should probably no lift more than 15 to 20 pounds maximally. She should probably not repetitively bend or stoop. She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand. She should probably not lift more than 10 pounds repetitively with the right upper extremity. I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity. , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04. There does not appear to be any apportionable issues here.

Qualified medical evaluation report of a patient with back pain.

Chiropractic

Qualified Medical Evaluation Report

HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,

Consultation for left foot pain.

Chiropractic

Foot pain Consultation

CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:, Left Chopart joint sprain.,PLAN:, I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.

The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

Consult - History and Phy.

Abdominal Pain - Consult

CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal." She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.

Consultation for wrist pain.

Chiropractic

Wrist Pain

CHIEF COMPLAINT:, Left wrist pain.,HISTORY OF PRESENT PROBLEM:,

MRI report Cervical Spine (Chiropractic Specific)

Chiropractic

MRI Cervical Spine - Chiropractic Specific

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

Chiropractic Evaluation for neck and low back pain following a car accident.

Chiropractic

Chiropractic Initial Evaluation - 2

SUBJECTIVE COMPLAINTS: ,Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. He has also experienced anxiety and nervousness.,PHYSICAL EXAMINATION: ,Height is 5'10". Weight is 270 pounds.,Visual Evaluation: The patient has anterior head carriage with rounded shoulders. He does not seem to be in any extreme distress. He has slight antalgic head position to the right.,Dynamometer Testing (grip strength) in pounds: The patient is right hand dominant. Right hand 110, 105, and 98. Left hand 80, 70, and 85.,Neurological: Sensation was normal in the upper and lower extremities. Motor strength +5/5 bilaterally in the upper extremities. Reflexes: Upper extremities +2/2 bilaterally, lower extremities patellar +0/2 bilaterally, and S1 +2/2 bilaterally.,Cervical spine range of motion:,Flexion 50/50 with moderate discomfort on the left.,Extension 50/60 with moderate discomfort on the left.,Right lateral bending 40/45 with moderate discomfort on the left.,Left lateral bending 40/45 with moderate discomfort on the right.,Right rotation 70/80 with moderate pain in the left.,Left rotation 70/80 with moderate pain in the left.,Lumbosacral range of motion:,Flexion 60/60.,Extension 25/25.,Right lateral bending 25/25.,Left lateral bending 25/25 with pain in the left.,Right rotation 30/30 with moderate discomfort in the right.,Left rotation 30/30.,Orthopedic Tests: Axial compression negative with moderate pain bilaterally. Shoulder distraction negative with moderate pain bilaterally. Maigne's test negative bilaterally. Valsalva normal and swallow test normal. Heel walk normal. Toe walk normal. Sitting root normal. SLR normal. Patrick-Faber's normal. Iliac compression caused moderate pain in the left.,RADIOLOGY FINDINGS:, X-rays of the cervical and lumbar will be taken today.,DIAGNOSES:,1. Cervical spine sprain/strain.,2. Lumbar spine sprain/strain.,3. Tension headaches.,CAUSATION: ,The patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. His history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. The patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.,PROGNOSIS: ,The likelihood of nearly complete symptomatic relief within 90 days is excellent. The patient should reach maximum medical improvement in three or four months.,TREATMENT/PLAN: ,After completing an initial examination evaluation, I have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. Treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. I feel it is too early to determine whether this patient will have any residuals or permanent disability.

Ventricular ectopy and coronary artery disease. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.

Cardiovascular / Pulmonary

Ventricular Ectopy - Consult

REASON FOR CONSULTATION:, Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS: ,I am seeing the patient upon the request of Dr. Y. The patient is a very well known to me. He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty. The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath. The patient was admitted and being treated for pneumonia, according to him. The patient denies any chest pain, chest pressure, or heaviness. Denies any palpitations, fluttering, or awareness of heart activity. However, on monitor, he was noticed to have PVCs random. He had run off three beats consecutive one time at 12:46 p.m. today. The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever or chills.,EYES: No visual disturbances.,ENT: No difficulty swallowing.,CARDIOVASCULAR: Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY: Cough and shortness of breath.,MUSCULOSKELETAL: Positive for arthritis and neck pain.,GU: Unremarkable.,NEUROLOGIC: Otherwise unremarkable.,ENDOCRINE: Otherwise unremarkable.,HEMATOLOGIC: Otherwise unremarkable.,ALLERGIC: Otherwise unremarkable.,PAST MEDICAL HISTORY:,1. Positive for coronary artery disease since 2002.,2. History of peripheral vascular disease for over 10 years.,3. COPD.,4. Hypertension.,PAST SURGICAL HISTORY:, Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1. Aspirin 81 mg daily.,2. Clopidogrel 75 mg daily.,3. Allopurinol 100 mg daily.,4. Levothyroxine 100 mcg a day.,5. Lisinopril 10 mg a day.,6. Metoprolol 25 mg a day.,7. Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION. HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:, No history of premature coronary artery disease. One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired. He has nine children, 25 grandchildren. He smokes one pack per day. He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT: Normocephalic and atraumatic. No thyromegaly or lymphadenopathy.,NECK: Supple.,CARDIOVASCULAR: Upstroke is normal. Distal pulse symmetrical. Heart regular with a normal S1 with normally split S2. There is an S4 at the apex.,LUNGS: With decreased air entry. No wheezes.,ABDOMINAL: Benign. No masses.,EXTREMITIES: No edema, cyanosis, or clubbing.,NEUROLOGIC: Awake, alert, and oriented x3. No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.

Insertion of a VVIR permanent pacemaker. This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias

Cardiovascular / Pulmonary

VVIR Permanent Pacemaker Insertion

PROCEDURE PERFORMED:, Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:, Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment. It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:, The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length. Overall options and precautions of the pacemaker and indications were all discussed. They agreed to the pacemaker. The consent was signed and placed in the chart. The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure. The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion. Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure. Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given. Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty. A guidewire was then passed through the Cook needle and the Cook needle was then removed. The wire was secured in place with the hemostat. Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia. The skin was then undermined used to make a pocket for the pacemaker. The guidewire was then tunneled through the pacer pocket. Cordis sheath was then inserted through the guidewire. The guidewire and dilator were removed. ___ cordis sheath was in placed within. This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy. It was placed into the apex. Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle. The lead was then connected on pulse generator. The pocket was then irrigated and cleansed. Pulse generator and the wire was then inserted into the ____ pocket. The skin was then closed with gut suture. The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique. The area was then cleansed and dried. Steri-Strips and pressure dressing was then applied. The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name: Sigma, model #: 12345, serial #: 123456.,VENTRICLE LEAD:, Model #: 12345, the ventricular lead serial #: 123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:, Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8. The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS: ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well. There was no complications. The patient went to recovery in stable condition. Chest x-ray will be ordered. She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care. If you have any questions or concerns, please feel free to contact.

Patient with worsening shortness of breath and cough.

Cardiovascular / Pulmonary

Trouble breathing

CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:, Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis. Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed. Psoriasis. She denied any history of miscarriage.,PAST SURGICAL HISTORY:, IVC filter placement 1999.

Right and Left carotid ultrasound

Cardiovascular / Pulmonary

Ultrasound - Carotid - 1

RIGHT:,1. Mild heterogeneous plaque seen in common carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5. Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1. Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2. Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3. Peak systolic velocity is normal in common carotid artery and in the bulb.,4. Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:, Antegrade flow seen bilaterally.

Need for intravenous access. Insertion of a right femoral triple lumen catheter. he patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.

Cardiovascular / Pulmonary

Triple Lumen Catheter Insertion - 1

PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED: ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:, The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site. The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:, The patient's legal guardian was talked to. All questions were answered and consent was obtained. The patient was sterilely prepped and draped. Approximately 4 cc of 1% lidocaine was injected into the inguinal site. A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated. A guidewire was then placed through the needle. The needle was then removed. The skin was ________ at the base of the wire and a dilator was placed over the wire. The triple lumen catheters were then flushed with bacteriostatic saline. The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed. Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports. Each port was closed off and also kept off. Straight needle suture was then used to suture the triple lumen catheter down to the skin. Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site. The surgical site was then sterilely cleaned. The patient tolerated the full procedure well. There were no complications. The nurse was then contacted to allow for access of the triple lumen catheter.

Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

Chiropractic

Chiropractic Progress Note

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.

Coronary artery bypass surgery and aortic stenosis. Transthoracic echocardiogram was performed of technically limited quality. Concentric hypertrophy of the left ventricle with left ventricular function. Moderate mitral regurgitation. Severe aortic stenosis, severe.

Cardiovascular / Pulmonary

Transthoracic Echocardiography

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

Bilateral carotid ultrasound to evaluate pain.

Cardiovascular / Pulmonary

Ultrasound - Carotid - 2

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

Urgent cardiac catheterization with coronary angiogram.

Cardiovascular / Pulmonary

Urgent Cardiac Cath

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest. The right groin was prepped and draped in usual manner. Under 2% lidocaine anesthesia, the right femoral artery was entered. A 6-French sheath was placed. The patient was already on anticoagulation. Selective coronary angiograms were then performed using a left and a 3DRC catheter. The catheters were reviewed. The catheters were then removed and an Angio-Seal was placed. There was some hematoma at the cath site.,RESULTS,1. The left main was free of disease.,2. The left anterior descending and its branches were free of disease.,3. The circumflex was free of disease.,4. The right coronary artery was free of disease. There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,

Transesophageal echocardiographic examination report. Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram - 3

REASON FOR EXAM: , Aortic valve replacement. Assessment of stenotic valve. Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS: ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:, Moderate stenosis of aortic valve replacement. Mild mitral regurgitation. Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits. The patient agreed and signed the consent form. The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control. The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt. In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm. Multiple pictures obtained. Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level. Different pictures including short-axis views of the aortic valve was done. Extubation done with no problems and no blood on the probe. The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated. No masses or thrombi were seen. The left atrial appendage was free of thrombus. Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH. EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse. There was mild-to-moderate regurgitation on color flow interrogation. Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed. No perivalvular leak was noticed. There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve. Overall showed no abnormalities. The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable. No dissection.,IMPRESSION:,1. Mildly dilated left atrium.,2. Mild-to-moderate regurgitation.,3. Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis. Reevaluation in two to three years with transthoracic echocardiogram will be recommended.

Transesophageal Echocardiogram. A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram - 6

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology. Please see also my cardiovascular consultation dictated separately. But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry. She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent. I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear. The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction. The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself. She received 20 cc of viscous lidocaine for topical oral anesthetic effect. She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect. The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition. This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout. She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function. LVEF of 60%. Mild left atrial enlargement. Normal right atrial size. Normal right ventricular size and systolic function. No left ventricular wall motion abnormalities identified. The four pulmonary veins are identified. The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage. No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves. The mitral valve is seen. There is mild mitral regurgitation with two jets. No mitral stenosis. Four pulmonary veins were identified without reversible pulmonary venous flow. There are three cusps of the aortic valve seen. No aortic stenosis. There is trace aortic insufficiency. There is trace pulmonic insufficiency. The pulmonary artery is seen and is within normal limits. There is trace to mild tricuspid regurgitation. Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study. E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds. The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm. The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits. The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale. No pericardial effusion. There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1. Normal left ventricular size and systolic function. Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2. Mild left atrial enlargement.,3. Intracardiac thrombus identified at the base of the left atrial appendage.,4. Mild mitral regurgitation with two jets.,5. Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.

Transesophageal echocardiogram. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram - 4

PROCEDURE NOTE:, The patient was brought to the transesophageal echo laboratory after informed consent was obtained. The patient was seen by Anesthesia for MAC anesthesia. The patient's posterior pharynx was anesthetized with local Cetacaine spray. The transesophageal probe was introduced into the posterior pharynx and esophagus without difficulty.,FINDINGS: ,1. Left ventricle is normal in size and function; ejection fraction approximately 60%.,2. Right ventricle is normal in size and function.,3. Left atrium and right atrium are normal in size.,4. Mitral valve, aortic valve, tricuspid valve, and pulmonic valve with no evidence of vegetation. Aortic valve is only minimally thickened.,5. Mild mitral regurgitation and mild tricuspid regurgitation.,6. No left ventricular thrombus.,7. No pericardial effusion.,8. There is evidence of patent foramen ovale by contrast study.,The patient tolerated the procedure well and is sent to recovery in stable condition. He should be n.p.o. x4 hours, then liquid, then increase as tolerated. Once his infection is cleared, he should follow up with us with regard to followup of patent foramen ovale.

Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram - 5

CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis. The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed. Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. There were no complications. The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1. Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2. Mitral valve is calcified and thick. No vegetation seen. There is mild-to-moderate MR present. There is mild AI present also.,3. Tricuspid valve and pulmonary valve are structurally normal.,4. There is a mild TR present.,5. There is no clot seen in the left atrial appendage. The velocity in the left atrial appendage was 0.6 m/sec.,6. Intraatrial septum was intact. There is no clot or mass seen.,7. Normal LV and RV systolic function.,8. There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1. There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. Calculated aortic valve area was 0.6 sq. cm.,2. Normal LV systolic function.,

Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function. Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram - 2

REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained. The patient was brought to special procedure unit. His throat was anesthetized with lidocaine spray. Subsequently, 2 mg of IV Versed was given for sedation. The patient was positioned. Probe was introduced without any difficulty. The patient tolerated the procedure very well. Probe was taken out. No complications were noted. Findings are as mentioned below.,FINDINGS:,1. Left ventricle has normal size and dimensions with normal function. Ejection fraction of 60%.,2. Left atrium and right-sided chambers were of normal size and dimensions.,3. Left atrial appendage is clean without any clot or smoke effect.,4. Atrial septum is intact. Bubble study was negative.,5. Mitral valve is structurally normal.,6. Aortic valve reveals echodensity suggestive of vegetation.,7. Tricuspid valve was structurally normal.,8. Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9. Aorta is benign.,IMPRESSION:,1. Normal left ventricular size and function.,2. Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.

Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.

Cardiovascular / Pulmonary

Transesophageal Echocardiography Probe

INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:, Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:, Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.,

Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension. Ventilator-dependent respiratory failure and laryngeal edema.

Cardiovascular / Pulmonary

Tracheostomy Change

PREOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1. Ventilator-dependent respiratory failure.,2. Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change. A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF. The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed. The patient was noted at that time to have transglottic edema. Biopsies were taken. At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection. The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support. A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit. The patient was placed in a supine position. The neck was then extended. The sutures that were previously in place in the #6 Shiley with proximal extension were removed. The patient was preoxygenated to 100%. After several minutes, the patient was noted to have a pulse oximetry of 100%. The IV tubing that was supporting the patient's trache was then cut. The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire. The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned. With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea. The guidewire was then removed and the inner cannula was then placed into the tracheostomy. The patient was then reconnected to the ventilator and was noted to have normal tidal volumes. The patient had a tidal volume of 500 and was returning 500 cc to 510 cc. The patient continued to saturate well with saturations 99%. The patient appeared comfortable and her vital signs were stable. A soft trache collar was then connected to the trachesotomy. A drain sponge was then inserted underneath the new trache site. The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well. 0.25% acetic acid soaks were ordered to the drain sponge every shift.

Tracheostomy with skin flaps and SCOOP procedure FastTract. Oxygen dependency of approximately 5 liters nasal cannula at home and chronic obstructive pulmonary disease.

Cardiovascular / Pulmonary

Tracheostomy & SCOOP Procedure

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

Transesophageal echocardiogram and direct current cardioversion.

Cardiovascular / Pulmonary

Transesophageal Echocardiogram

EXAM: , Transesophageal echocardiogram and direct current cardioversion.,REASON FOR EXAM: ,1. Atrial fibrillation with rapid ventricular rate.,2. Shortness of breath.,PROCEDURE: , After informed consent was obtained, the patient was then sedated using a total of 4 mg of Versed and 50 mcg of fentanyl. Following this, transesophageal probe was placed in the esophagus. Transesophageal views of the heart were then obtained.,FINDINGS:,1. Left ventricle is of normal size. Overall LV systolic function is preserved. Estimated ejection fraction is 60% to 65%. No wall motion abnormalities are noted.,2. Left atrium is dilated.,3. Left atrial appendage is free of clots.,4. Right atrium is of normal size.,5. Right ventricle is of normal size.,6. Mitral valve shows evidence of mild MAC.,7. Aortic valve is sclerotic without significant restriction of leaflet motion.,8. Tricuspid valve appears normal.,9. Pulmonic valve appears normal.,10. Pacer wires are noted in the right atrium and in the right ventricle.,11. Doppler interrogation of moderate mitral regurgitation is present.,12. Mild-to-moderate AI is seen.,13. No significant TR is noted.,14. No significant TI is noted.,15. No pericardial disease seen.,IMPRESSION:,1. Preserved left ventricular systolic function.,2. Dilated left atrium.,3. Moderate mitral regurgitation.,4. Aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5. Left atrial appendage is free of clots.,Following these, direct current cardioversion was performed. Three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm. The patient remained in atrial fibrillation.,PLAN: , Plan will be to continue medical therapy. We will consider using beta-blocker, calcium channel blockers for better ventricular rate control.

Tilt table test. A patient with past medical history of syncope. The patient is also complaining of dizziness.

Cardiovascular / Pulmonary

Tilt Table Test - 1

INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89. She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80. Then, the patient received sublingual nitroglycerin 0.4 mg. The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50. The patient felt nauseous and felt hot at that time. She did not pass out.,COMPLICATIONS:, None.,Tilt table was then terminated.,SUMMARY:, Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist.

Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.

Cardiovascular / Pulmonary

Tracheostomy Tube Consult

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

Tracheotomy for patient with respiratory failure.

Cardiovascular / Pulmonary

Tracheotomy - 1

PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS: ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA: ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table. General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube. The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined. The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring. The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000. A #67 blade was used to perform the incision. Electrocautery was used to remove excess fat tissue to expose the strap muscles. The strap muscles were grasped and divided in the midline with a cutting electrocautery. Sharp dissection was used to expose the anterior trachea and cricoid cartilage. The thyroid isthmus was identified crossing just below the cricoid cartilage. This was divided in the midline with electrocautery. Blunt dissection was used to expose adequate cartilaginous rings. A 4.0 silk was used for stay sutures to the midline of the cricoid. Additional stay sutures were placed on each side of the third tracheal ring. Thin DuoDerm was placed around the stoma. The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings. The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl. A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties. A flexible scope was passed through the tracheotomy tube. The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube. Ventilation was confirmed. There was good chest rise and no appreciable leak. The procedure was terminated. The patient was in stable condition. Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.

Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia. Thrombectomy of the left forearm loop graft. The venous outflow was good. There was stenosis in the mid-venous limb of the graft.

Cardiovascular / Pulmonary

Thrombectomy

PREOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1. Thrombosed left forearm loop fistula graft.,2. Chronic renal failure.,3. Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:, The venous outflow was good. There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft. She was not able to have her dialysis as routine. Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery. Both Surgery and Anesthesia thought this would be too risky to do. Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning. This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion. A transverse incision was made at the region of the venous anastomosis of the graft. Further dissection was carried down to the catheter. The vein appeared to be soft and without thrombus. This outflow did not appear to be significantly impaired. A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis. Next, a thrombectomy was done using a #4 Fogarty catheter. Some of the clot and thrombus was removed from the venous limb. The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis. Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis. At this point, we felt the patient would benefit from a curettage of the venous limb of the graft. This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage. The Fogarty balloon was then passed beyond the clot and the plug. The plug was visualized and inspected. This also gave a good brisk bleeding from the graft. The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb. Attention was directed up to its anastomosis and the vein. Fogarty balloon and thrombectomy was also performed well enough into this way. There was good venous back bleeding following this. The area was checked for any stenosis with the dilators and none was present. Next, a #6-0 Prolene suture was used in a running fashion to close the graft. Just prior to tying the suture, the graft was allowed to flush to move any debris or air. The suture was also checked at that point for augmentation, which was good. The suture was tied down and the wound was irrigated with antibiotic solution. Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges. Steri-Strips were applied and the patient was taken to recovery in stable condition. She tolerated the procedure well. She will be discharged from recovery when stable. She is to resume her regular dialysis schedule and present for dialysis tomorrow.

Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.

Cardiovascular / Pulmonary

Thromboendarterectomy

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

Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis. Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.

Cardiovascular / Pulmonary

Thrombectomy AV Shunt

PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS: ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE: ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE: ,The left arm was prepped and draped. Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop. The runoff vein was dissected out and encircled with the vessel loop as well. A longitudinal incision was made over the venous anastomosis. There was a narrowing in the area and slightly the incision was extended more proximally. There was good back bleeding from the vein as well as bleeding from the more distal vein. These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously. A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established. There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator. The Fogarty catheter was then passed up the vein, but no clot was obtained. A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture. Clamps were removed and flow established. A thrill was easily palpable. Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.

Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.

Cardiovascular / Pulmonary

Thoracotomy & Lobectomy

PREOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,POSTOPERATIVE DIAGNOSES:,1. Non-small-cell carcinoma of the left upper lobe.,2. History of lymphoma in remission.,PROCEDURE: , Left muscle sparing mini thoracotomy with left upper lobectomy and mediastinal lymph node dissection. Intercostal nerve block for postoperative pain relief at five levels.,INDICATIONS FOR THE PROCEDURE: , This is an 84-year-old lady who was referred by Dr. A for treatment of her left upper lobe carcinoma. The patient has a history of lymphoma and is in remission. An enlarged right axillary lymph node was biopsied recently and was negative for lymphoma. A mass in the left upper lobe was biopsied with fine-needle aspiration and shown to be a primary non-small-cell carcinoma of the lung. PET scan was, otherwise, negative for spread and resection was advised. All the risk and benefits were fully explained to the patient and she elected to proceed as planned. She was transferred to rehab for couple of weeks to buildup strength before the surgery.,PROCEDURE IN DETAIL:, In the operating room under anesthesia, she was prepped and draped suitably. Dr. B was the staff anesthesiologist. Left muscle sparing mini thoracotomy was made. The serratus and latissimus muscles were not cut but moved out to the way. Access to the chest was obtained through the fifth intercostal space. Two Tuffier retractors of right angles provided adequate exposure.,The inferior pulmonary ligament was not dissected free and lymph nodes from the station 9 were now sent for pathology. The parietal pleural reflexion around the hilum was now circumcised, and lymph nodes were taken from station 8 and station 5.,The branches of the pulmonary artery to the upper lobe were now individually stapled with a 30/2.5 staple gun or/and the smaller one were ligated with 2-0 silk. The left superior pulmonary vein was transected using a TA30/2.5 staple gun, and the fissure was completed using firings of an endo-GIA 60/4.8 staple gun. Finally, the left upper lobe bronchus was transected using a TA30/4.8 staple gun. Please note, that this patient had been somewhat unusual variant of a small bronchus that was coming out posterior to the main trunk of the pulmonary artery and supplying a small section of the posterior portion of the left upper lobe.,The specimen was delivered and sent to pathology. The mass was clearly palpable in the upper portion of the lingular portion of this left upper lobe. Frozen section showed that the margin was negative.,The chest was irrigated with warm sterile water and when the left lower lobe inflated, there was no air leak. A single 32-French chest tube was inserted, and intercostal block was done with Marcaine infiltrated two spaces above and two spaces below thus achieving a block at five levels 30 mL of Marcaine was used all together. A #2 Vicryl pericostal sutures were now applied. The serratus and latissimus muscles retracted back in place. A #19 French Blake drain placed in the subcutaneous tissues and 2-0 Vicryl used for the fat followed by 4-0 Monocryl for the skin. The patient was transferred to the ICU in a stable condition.

Left thoracotomy with total pulmonary decortication and parietal pleurectomy. Empyema of the chest, left.

Cardiovascular / Pulmonary

Thoracotomy & Pleurectomy

PREOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,POSTOPERATIVE DIAGNOSIS: , Empyema of the chest, left.,PROCEDURE: , Left thoracotomy with total pulmonary decortication and parietal pleurectomy.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube. A time-out process had been followed and preoperative antibiotics were given.,The patient was positioned with the left side up for a left thoracotomy. The patient was prepped and draped in the usual fashion. A posterolateral thoracotomy was performed. It included the previous incision. The chest was entered through the fifth intercostal space. Actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke. Thanks to Dr. X's ingenuity, we were able to reuse the chest retractor and opened the chest after I incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura. We aspirated an abundant amount of pus from this cavity. The sample was taken for culture and sensitivity.,Then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm. Once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung. Further samples for culture and sensitivity were sent.,Then, we were left with the trapped lung. It was trapped by thickened visceral pleura. This was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively. Finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily. There was only one area towards the mediastinum that apparently I was not able to fill. This area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so I restrained from doing that. Two large chest tubes were placed. The cavity had been abundantly irrigated with warm saline. Then, the thoracotomy was closed in layers using heavy stitches of Vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,The chest tubes were affixed to the skin with heavy sutures of silk. Dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,Estimated blood loss was about 500 mL. The patient tolerated the procedure very well and was sent to the ICU in a satisfactory condition.

Tilt table test. Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.

Cardiovascular / Pulmonary

Tilt Table Test

FINDINGS:,1. The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2. There was no significant change in heart rate or blood pressure on 80-degree tilt.,3. No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.

Empyema. Right thoracotomy, total decortication and intraoperative bronchoscopy. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.

Cardiovascular / Pulmonary

Thoracotomy & Bronchoscopy

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

Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

Cardiovascular / Pulmonary

Thoracotomy & Esophageal Exploration

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

Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.

Cardiovascular / Pulmonary

Thoracoscopy/Thoracotomy

PREOPERATIVE DIAGNOSES:, Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:, Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:, General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. There was also noted to be some mild infiltrates of the right lung. The patient had a 30-year history of cigarette smoking. A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT. The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. This was suctioned out with the addition of the use of saline ***** in the bronchus. Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment. Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. There were many pockets of purulent material, which had a gray-white appearance to it. There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. Many cultures were taken from several areas. The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:, With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. Suture ligatures of Prolene were required. When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed. The patch was sutured onto the pulmonary artery tear. A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel. After reasonably good hemostasis was established pleural cavity was irrigated with saline. As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed. Sponge count was reported as being correct. Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl. The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin. The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. Sterile dressings were applied. The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.

A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.

Cardiovascular / Pulmonary

Thoracoabdominal Aneurysm

POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube. Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle. The left groin, abdominal and chest were prepped and draped in a sterile fashion. A thoracoabdominal incision was made. The 8th interspace was entered. The costal margin was divided. The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta. The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm. It was dissected free circumferentially. The aortic bifurcation was dissected free, dissecting free both iliac arteries. The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this. The patient was heparinized. Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet. This was hooked to a venous inflow of left heart bypass machine. A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow. Bypass was instituted. The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm. The area was divided at this point. A 26-mm graft was then sutured in place with running 3-0 Prolene suture. The graft was brought into the diaphragm. Clamps were then placed on the iliacs, and the pump was shut off. The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation. The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch. The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference. The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels. The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture. All clamps were removed, and flow was re-established. An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal. A partial-occlusion clamp was placed. An area of graft was removed. The end of the graft was cut to fit this and sutured in place with running Prolene suture. The partial-occlusion clamp was removed. Protamine was given. Good hemostasis was noted. The arterial cannula, of course, had been removed when that part of the aneurysm was removed. The venous cannula was removed and oversewn with a 4-0 Prolene suture. Good hemostasis was noted. A 36 French posterior and a 32 French anterior chest tube were placed. The ribs were closed with figure-of-eight #2 Vicryl. The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch. Patient tolerated the procedure well.

Left mesothelioma, focal. Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.

Cardiovascular / Pulmonary

Thoracoscopy & Thoracotomy - Mesothelioma

PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION: ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.

The patient was originally hospitalized secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.

Cardiovascular / Pulmonary

Telemetry Monitoring

DIAGNOSES PROBLEMS:,1. Orthostatic hypotension.,2. Bradycardia.,3. Diabetes.,4. Status post renal transplant secondary polycystic kidney disease in 1995.,5. Hypertension.,6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. History of renal osteodystrophy.,8. Iron deficiency anemia.,9. Cataract status post cataract surgery.,10. Chronic left lower extremity pain.,11. Hyperlipidemia.,12. Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:, Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1. CellCept - 500 mg twice a daily.,2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3. Prednisone - 5 mg once daily.,4. Hydralazine - 10 mg four times a day.,5. Pantoprazole - 40 mg once daily.,6. Glipizide - 5 mg every morning.,7. Aspirin - 81 mg once daily.,FOLLOWUP CARE: ,The patient is to follow up with Dr. X in about 1 week's time.

Insertion of right internal jugular Tessio catheter and placement of left wrist primary submental arteriovenous fistula.

Cardiovascular / Pulmonary

Tessio Catheter Insertion

OPERATIONS/PROCEDURES,1. Insertion of right internal jugular Tessio catheter.,2. Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well.

Thoracentesis. Left pleural effusion. Left hemothorax.

Cardiovascular / Pulmonary

Thoracentesis

PREOPERATIVE DIAGNOSIS:, Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:, Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:, After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.

Thoracentesis, left. Malignant pleural effusion, left, with dyspnea.

Cardiovascular / Pulmonary

Thoracentesis - 1

PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE: ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room. After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion. Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line. Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall. Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid. From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle. At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine. At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation. We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,

Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.

Cardiovascular / Pulmonary

Tesio Hemodialysis Catheter Insertion

OPERATION,1. Insertion of a left subclavian Tesio hemodialysis catheter.,2. Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered. Next, the patient's chest and neck were prepped and draped in the standard surgical fashion. Lidocaine 1% was used to infiltrate the skin in the region of the procedure. Next a #18-gauge finder needle was used to locate the left subclavian vein. After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle. This process was repeated. The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy. Next, the subcutaneous tunnel was created. The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff. A dilator and sheath were passed over the individual J wires. The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn. The process was repeated. Both distal tips were noted to be in good position. The Tesio hemodialysis catheters were flushed and aspirated without difficulty. The catheters were secured at the cuff level with a 2-0 nylon. The skin was closed with 4-0 Monocryl. Sterile dressing was applied. The patient tolerated the procedure well and was transferred to the PACU in good condition.

The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy. She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy. She is now referred to the thoracic surgery clinic for evaluation.

Cardiovascular / Pulmonary

Supraclavicular Lymphadenopathy

On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure. She has had negative PPD.,PAST MEDICAL HISTORY:, Hypertension.,PAST SURGICAL HISTORY:, Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore. She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation: She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:, Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP: 133/72

Subxiphoid pericardiotomy. Symptomatic pericardial effusion. The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.

Cardiovascular / Pulmonary

Subxiphoid Pericardiotomy

PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:, Subxiphoid pericardiotomy.,ANESTHESIA:, General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:, This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003. She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion. She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic. Also, during that time, she had become significantly more short of breath. A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions. She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion. Risks, benefits, and alternative measures were discussed with the patient. Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was created in the midline above the xiphoid. Dissection was carried down through the fascia and the xiphoid was resected. The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium. An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization. Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc. A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed. The heart was visualized and appeared to be contracting well with no evidence of injury to the heart. The pericardium was then palpated. There was no evidence of studding. A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium. It was sewn into place with #0 silk suture. There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium. It was sewn in the similar way to the other chest tube. Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion. The patient tolerated the procedure well. Chest tubes were placed on 20 cm of water suction. The patient was taken to PACU in stable condition.

Emergent subxiphoid pericardial window, transesophageal echocardiogram.

Cardiovascular / Pulmonary

Subxiphoid Pericardial Window

PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.

Insertion of right subclavian central venous catheter. Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.

Cardiovascular / Pulmonary

Subclavian Central Venous Catheter Insertion

PREOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Need for intravenous access.,2. Status post fall.,3. Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries. The patient went to OR today for an I&D of left lower extremity degloving injury. Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter. All risks and benefits of the procedure were explained and all questions were answered. The patient was prepped and draped in the normal sterile fashion. After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid. Locator needle was used to correctly cannulate the right internal jugular vein. Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach. The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle. A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch. The right subclavian vein was then accessed. A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin. A dilator sheath was placed over the guidewire and subsequently removed. The triple lumen catheter was then placed over the guidewire and advanced to 14 cm. All ports aspirated and flushed. Good blood return was noted and all ports were flushed well. The triple lumen catheter was then secured at 14 cm using #0 silk suture. A sterile dressing was then applied. A stat portable chest x-ray was ordered to check line placement. The patient tolerated the procedure well and there were no complications.

Thallium stress test for chest pain.

Cardiovascular / Pulmonary

Stress Test Thallium

INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:,

Chest pain, hypertension. Stress test negative for dobutamine-induced myocardial ischemia. Normal left ventricular size, regional wall motion, and ejection fraction.

Cardiovascular / Pulmonary

Stress Test Dobutamine Myoview

INDICATIONS: ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:, Dobutamine Myoview stress test.,STRESS ECG RESULTS:, The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes. Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion. The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality. The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate. The blood pressure increased from 130/80 to 160/70. A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion. No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:, Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview. Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview. The lung heart ratio is 0.36. Myocardial perfusion images were normal both at rest and with stress. Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1. Stress test is negative for dobutamine-induced myocardial ischemia.,2. Normal left ventricular size, regional wall motion, and ejection fraction.

Subxiphoid pericardial window. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery.

Cardiovascular / Pulmonary

Subxiphoid Pericardial Window - 1

OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL: ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered. Next, the neck and chest were prepped and draped in the standard surgical fashion. A #10-blade scalpel was used to make an incision in the area of the xiphoid process. Dissection was carried down to the level of the fascia using Bovie electrocautery. The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free. Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery. Upon entering the pericardium, serous fluid was expressed. In total, ** cc of fluid was drained. A pericardial biopsy was obtained. The fluid was sent off for cytologic examination as well as for culture. A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium. The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion. Sterile dressing was applied.

Stress test - Adenosine Myoview. Ischemic cardiomyopathy. Inferoseptal and apical transmural scar.

Cardiovascular / Pulmonary

Stress Test Adenosine Myoview

INDICATIONS:, Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:, Adenosine Myoview stress test.,STRESS ECG RESULTS:, The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute. Underlying atrial fibrillation noted, very wide QRS complexes. The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.

Dobutamine stress test for atrial fibrillation.

Cardiovascular / Pulmonary

Stress Test Dobutamine

INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:, It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.,CONCLUSIONS:,1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. Normal LV myocardial perfusion.,3. Normal LV systolic ejection fraction of 65%.,4. Normal global and regional wall motion.

Stress test with Bruce protocol due to chest pain.

Cardiovascular / Pulmonary

Stress Test Bruce Protocol

PROTOCOL:, Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:, Chest pain.,PROCEDURE AND INTERPRETATION: ,1. Baseline heart rate: 67.,2. Baseline blood pressure: 150/86.,3. Total time: 6 minute 51 seconds.,4. METs: 10.1.,5. Peak heart rate: 140.,6. Percent of maximum-predicted heart rate: 90.,7. Peak blood pressure: 200/92.,8. Reason test terminated: Shortness of breath and fatigue.,9. Estimated aerobic capacity: Average.,10. Heart rate response: Normal.,11. Blood pressure response: Hypertensive.,12. ST segment response: Normal.,13. Chest pain: None.,14. Symptoms: None.,15. Arrhythmia: None.,CONCLUSION:,1. Average aerobic capacity.,2. Normal heart rate and blood pressure response to exercise.,3. No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION: ,The patient was discharged home and was asymptomatic.,

Sick sinus syndrome, atrial fibrillation, pacemaker dependent, mild cardiomyopathy with ejection fraction 40% and no significant decompensation, and dementia of Alzheimer's disease with short and long term memory dysfunction

Cardiovascular / Pulmonary

Sick Sinus Syndrome

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility. The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney. The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1. Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. Dementia of Alzheimer's disease.,3. Gastroesophageal reflux disease.,4. Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility. He is nonsmoker, nondrinker. He uses wheelchair and moves himself about with his feet. He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS: ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. Negative for recent falls. Positive for significant memory loss. All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS: Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT: Head atraumatic and normocephalic. Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR: No JVD or no jugular venous distention. No carotid bruits bilaterally. Pacemaker pocket right upper thorax with healed surgical incisions. S1 and S2 are normal. No S3 or S4. There are no murmurs. No heaves or thrills, gout, or gallops. Trace edema at dorsum of his feet and ankles. Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY: Breath sounds are clear but diminished throughout AP diameters expanded. The patient speaks in full sentences. No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL: Abdomen is soft and nontender. Bowel sounds are active in all 4 quadrants. No palpable pulses. No abdominal bruit is appreciated. No hepatosplenomegaly.,GENITOURINARY: Nonfocal.,MUSCULOSKELETAL: Muscle strength in lower extremities is 4/5 bilaterally. Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN: Warm and dry. No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC: Alert, not oriented to place and date. His speech is clear. There are no focal motor or sensory deficits.,PSYCHIATRIC: Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:, Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:, St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI. A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80. No Q waves at the baseline of atrial fibrillation. Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1. Sick sinus syndrome.,2. Atrial fibrillation.,3. Pacemaker dependent.,4. Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. Pacemaker battery end of life requiring exchange.,6. Dementia of Alzheimer's disease with short and long term memory dysfunction. The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. I explain the patient and reimplantation with any device in the surgical suite. He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. Admit the patient after surgery for postoperative care and monitoring.

Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.

Cardiovascular / Pulmonary

Stenting

NAME OF PROCEDURE:, Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:, Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:, Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION: ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.,GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.,HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.,NECK: Supple. Tracheostomy site is clean without blood or discharge.,HEART: Regular rate and rhythm. No gallop, murmur or rub.,CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.,ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.,GENITALIA: The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:, The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.